Provider Demographics
NPI:1104852144
Name:MCKENNA, CANDACE C (NP)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:C
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MEDICAL CENTER BLVD
Mailing Address - Street 2:ER
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3147
Mailing Address - Country:US
Mailing Address - Phone:504-349-1533
Mailing Address - Fax:504-349-1530
Practice Address - Street 1:1101 MEDICAL CENTER BLVD
Practice Address - Street 2:ER
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3147
Practice Address - Country:US
Practice Address - Phone:504-349-1533
Practice Address - Fax:504-349-1530
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113883363L00000X
LAAP07717363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000832752EMedicaid
GA000832752CMedicaid
GA000832752BMedicaid
GA000832752AMedicaid
SCNP0335Medicaid
GA10059157OtherAMERIGROUP
SCNP0335Medicaid
S84518Medicare UPIN
GA000832752BMedicaid