Provider Demographics
NPI:1609255611
Name:MCKINNIS, ROY
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:MCKINNIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 GRANITE DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2883
Mailing Address - Country:US
Mailing Address - Phone:434-548-8752
Mailing Address - Fax:
Practice Address - Street 1:5229 HALIFAX RD
Practice Address - Street 2:
Practice Address - City:HALIFAX
Practice Address - State:VA
Practice Address - Zip Code:24558-3179
Practice Address - Country:US
Practice Address - Phone:434-548-8752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-151054376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide