Provider Demographics
NPI:1578640843
Name:MCKINNON, NANCY LYNN (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:LYNN
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14225 COPPER AVE NE
Mailing Address - Street 2:G707
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-1859
Mailing Address - Country:US
Mailing Address - Phone:505-294-8380
Mailing Address - Fax:
Practice Address - Street 1:505 ELM ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2500
Practice Address - Country:US
Practice Address - Phone:505-727-3067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3235225100000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer