Provider Demographics
NPI:1336132307
Name:MCKANNA, REBECCA M (NP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:MCKANNA
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:148 EAST AVE
Mailing Address - Street 2:SUITE3H
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5721
Mailing Address - Country:US
Mailing Address - Phone:203-354-6100
Mailing Address - Fax:203-354-6182
Practice Address - Street 1:1600 116TH AVE NE
Practice Address - Street 2:SUITE 102
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3014
Practice Address - Country:US
Practice Address - Phone:425-454-5311
Practice Address - Fax:425-454-8188
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2010-10-04
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Provider Licenses
StateLicense IDTaxonomies
MA254985363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0701700Medicaid
MA0701700Medicaid
MANP4829Medicare ID - Type Unspecified