Provider Demographics
NPI:1174185128
Name:NEWELL, MCKENNA ALEXANDRA (ATC)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:ALEXANDRA
Last Name:NEWELL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 N 16TH ST APT 2097
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7177
Mailing Address - Country:US
Mailing Address - Phone:760-567-3555
Mailing Address - Fax:
Practice Address - Street 1:3300 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-3030
Practice Address - Country:US
Practice Address - Phone:760-567-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-30
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0016302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer