Provider Demographics
NPI:1770697211
Name:MCCOY, SANDRA DEE (APRN)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:DEE
Last Name:MCCOY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:SANDRA
Other - Middle Name:DEE
Other - Last Name:MULLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 636493
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6493
Mailing Address - Country:US
Mailing Address - Phone:513-981-5130
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:749 IRVINE RD
Practice Address - Street 2:
Practice Address - City:CLAY CITY
Practice Address - State:KY
Practice Address - Zip Code:40312-9732
Practice Address - Country:US
Practice Address - Phone:606-663-2153
Practice Address - Fax:606-663-7966
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002780363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78002631Medicaid
KY607850200OtherFEDERAL BLACK LUNG
KY78002631Medicaid
KY607850200OtherFEDERAL BLACK LUNG