1336132307 NPI number — REBECCA M MCKANNA NP

Table of content: REBECCA M MCKANNA NP (NPI 1336132307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336132307 NPI number — REBECCA M MCKANNA NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKANNA
Provider First Name:
REBECCA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336132307
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
148 EAST AVE
Provider Second Line Business Mailing Address:
SUITE3H
Provider Business Mailing Address City Name:
NORWALK
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06851-5721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-354-6100
Provider Business Mailing Address Fax Number:
203-354-6182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 116TH AVE NE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98004-3014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-454-5311
Provider Business Practice Location Address Fax Number:
425-454-8188
Provider Enumeration Date:
08/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  254985 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0701700 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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