Provider Demographics
NPI:1245703875
Name:MCCOY, KRISTIN RAE
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:RAE
Last Name:MCCOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 PALMER LN
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-2907
Mailing Address - Country:US
Mailing Address - Phone:801-400-4507
Mailing Address - Fax:
Practice Address - Street 1:61 N WILLOW ST STE 4
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-4786
Practice Address - Country:US
Practice Address - Phone:702-346-4696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV88-66000022Medicaid