Provider Demographics
NPI:1295379816
Name:MCCOY, ANBREA DOMIKA
Entity type:Individual
Prefix:
First Name:ANBREA
Middle Name:DOMIKA
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 1:3810 REGENCY PKWY APT 301
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-3317
Mailing Address - Country:US
Mailing Address - Phone:240-330-5653
Mailing Address - Fax:
Practice Address - Street 1:140 T ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-1579
Practice Address - Country:US
Practice Address - Phone:240-353-7469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM200067149234372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC000000000Medicaid