Provider Demographics
NPI:1275689788
Name:MCKINNEY, COLLEEN J (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:J
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:120 STURGES AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2399
Mailing Address - Country:US
Mailing Address - Phone:419-522-5454
Mailing Address - Fax:419-522-2981
Practice Address - Street 1:540 S TRIMBLE RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-3418
Practice Address - Country:US
Practice Address - Phone:419-522-5454
Practice Address - Fax:419-522-2981
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35177063M208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2230446Medicaid