Healthcare Provider Details

I. General information

NPI: 1558606897
Provider Name (Legal Business Name): KHADJA MAYCOCK ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 W COLONIAL DR SUITE 187
OCOEE FL
34761-3400
US

IV. Provider business mailing address

10000 W COLONIAL DR SUITE 187
OCOEE FL
34761-3400
US

V. Phone/Fax

Practice location:
  • Phone: 407-578-6610
  • Fax:
Mailing address:
  • Phone: 407-578-6610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9203957
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: