Provider Demographics
NPI:1568913952
Name:MCCONNELL, MARKEYA
Entity Type:Individual
Prefix:
First Name:MARKEYA
Middle Name:
Last Name:MCCONNELL
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 1:815 W CRESTVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-4116
Mailing Address - Country:US
Mailing Address - Phone:951-376-3633
Mailing Address - Fax:
Practice Address - Street 1:815 W CRESTVIEW ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-4116
Practice Address - Country:US
Practice Address - Phone:951-570-7467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34936167G00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician