Provider Demographics
NPI:1255698270
Name:MCCOY, AMBER JEAN
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:JEAN
Last Name:MCCOY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:AMBER
Other - Middle Name:JEAN
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN GXMO
Mailing Address - Street 1:6114 GATE TREE LANE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-2746
Mailing Address - Country:US
Mailing Address - Phone:260-486-2880
Mailing Address - Fax:
Practice Address - Street 1:6114 GATE TREE LANE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-2746
Practice Address - Country:US
Practice Address - Phone:260-486-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.304895163W00000X
IN28142320A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse