Provider Demographics
NPI:1083304430
Name:MCKINNEY, ANDREA MONIQUE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MONIQUE
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2490 GRINSTEAD DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-2367
Mailing Address - Country:US
Mailing Address - Phone:502-550-2897
Mailing Address - Fax:
Practice Address - Street 1:13010 EASTGATE PARK WAY STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3984
Practice Address - Country:US
Practice Address - Phone:502-244-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY284782225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist