Provider Demographics
NPI:1407875602
Name:MCKINNELL, ELIZABETH JEANNE (APRN, NP-C)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:JEANNE
Last Name:MCKINNELL
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:143 S END AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06422-2903
Mailing Address - Country:US
Mailing Address - Phone:860-349-1182
Mailing Address - Fax:
Practice Address - Street 1:162 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1711
Practice Address - Country:US
Practice Address - Phone:203-239-4071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE34419363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236007Medicaid