Provider Demographics
NPI:1407320609
Name:MCKENNA, STEPHANIE N (PT DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:N
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:PT DPT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:NICOLE
Other - Last Name:SARANDOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3620 JOSEPH SIEWICK DR STE 106
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1757
Mailing Address - Country:US
Mailing Address - Phone:703-391-2450
Mailing Address - Fax:703-391-3142
Practice Address - Street 1:3620 JOSEPH SIEWICK DR STE 106
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1757
Practice Address - Country:US
Practice Address - Phone:703-391-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPT872276225100000X
MD27340225100000X
VA2305211999225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist