Provider Demographics
NPI:1467181644
Name:STANLEY, MCKENNA AVERY
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:AVERY
Last Name:STANLEY
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 1:2305 ERICA WAY
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-6744
Mailing Address - Country:US
Mailing Address - Phone:210-643-0140
Mailing Address - Fax:
Practice Address - Street 1:2960 ELDORADO PKWY STE 75
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-7500
Practice Address - Country:US
Practice Address - Phone:972-562-0713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1360726225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist