Provider Demographics
NPI:1437766995
Name:MCKERNAN, SUE ANN
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:ANN
Last Name:MCKERNAN
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 1:11553 NW 115TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IA
Mailing Address - Zip Code:50109-9705
Mailing Address - Country:US
Mailing Address - Phone:515-473-2574
Mailing Address - Fax:
Practice Address - Street 1:1801 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1548
Practice Address - Country:US
Practice Address - Phone:515-282-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAH160360363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health