Provider Demographics
NPI:1356689251
Name:MCKENNEY, SAMONICA
Entity Type:Individual
Prefix:
First Name:SAMONICA
Middle Name:
Last Name:MCKENNEY
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 1:5736 NORTH TRYON ST
Mailing Address - Street 2:STE 220
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-0823
Mailing Address - Country:US
Mailing Address - Phone:704-790-3302
Mailing Address - Fax:704-790-3302
Practice Address - Street 1:5736 NORTH TRYON ST
Practice Address - Street 2:STE 220
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-0823
Practice Address - Country:US
Practice Address - Phone:704-790-3302
Practice Address - Fax:704-790-3302
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3948376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601935Medicaid