Provider Demographics
NPI:1427415421
Name:MCKINNISS, LUCY B (DC)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:B
Last Name:MCKINNISS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:B
Other - Last Name:KENNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:5400 S WILLIAMSON BLVD APT 3-310
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1620 S CLYDE MORRIS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119-9008
Practice Address - Country:US
Practice Address - Phone:286-944-9740
Practice Address - Fax:386-944-9739
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11771111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor