Healthcare Provider Details

I. General information

NPI: 1518417856
Provider Name (Legal Business Name): KRISTEN CARROLL MCCOY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 LAKELAND DR STE 61
JACKSON MS
39216-4682
US

IV. Provider business mailing address

970 LAKELAND DR STE 61
JACKSON MS
39216-4682
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-7850
  • Fax: 601-366-8507
Mailing address:
  • Phone: 601-982-7850
  • Fax: 601-366-8507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901718
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: