Basic Information
Provider Information | |||||||||
NPI: | 1518317072 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCOY | ||||||||
FirstName: | CHARIS | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JONES | ||||||||
OtherFirstName: | CHARIS | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1122 N TOPEKA ST | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672142810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3168662000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10004 204TH AVE E | ||||||||
Address2: |   | ||||||||
City: | BONNEY LAKE | ||||||||
State: | WA | ||||||||
PostalCode: | 983916539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538485951 | ||||||||
FaxNumber: | 2538457073 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2016 | ||||||||
LastUpdateDate: | 03/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 77276 | KS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.