Provider Demographics
NPI:1588210645
Name:MCKENNA, STEPHANIE JILL (LPN)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JILL
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CARLDON RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1610
Mailing Address - Country:US
Mailing Address - Phone:646-643-7708
Mailing Address - Fax:
Practice Address - Street 1:600 S SERVICE RD
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6015
Practice Address - Country:US
Practice Address - Phone:631-271-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY621817-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse