Healthcare Provider Details

I. General information

NPI: 1487500575
Provider Name (Legal Business Name): JAMICAH LILLIE MCCOY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2090 S HIGHWAY 29
CANTONMENT FL
32533-8699
US

IV. Provider business mailing address

2090 S HIGHWAY 29
CANTONMENT FL
32533-8699
US

V. Phone/Fax

Practice location:
  • Phone: 850-937-0122
  • Fax: 850-937-1522
Mailing address:
  • Phone: 866-389-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11045934
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: