Provider Demographics
NPI:1497756787
Name:MCKINNEY, SUSANNE S (NP)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:S
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSANNE
Other - Middle Name:S
Other - Last Name:BRADFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:10461 WALLACE ALLEY ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-3936
Mailing Address - Country:US
Mailing Address - Phone:423-279-1400
Mailing Address - Fax:423-279-1410
Practice Address - Street 1:10461 WALLACE ALLEY ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-3936
Practice Address - Country:US
Practice Address - Phone:423-279-1400
Practice Address - Fax:423-279-1410
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5221163WG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0100XNursing Service ProvidersRegistered NurseGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3908885Medicaid
TNP75841Medicare UPIN
TN3908885Medicaid