Provider Demographics
NPI:1639769532
Name:MCKINNEY, RICKANESHA (HAIR LOSS SP)
Entity Type:Individual
Prefix:
First Name:RICKANESHA
Middle Name:
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:HAIR LOSS SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MENCY PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:NC
Mailing Address - Zip Code:28365-2801
Mailing Address - Country:US
Mailing Address - Phone:919-920-3923
Mailing Address - Fax:
Practice Address - Street 1:1020 S BREAZEALE AVE
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-8572
Practice Address - Country:US
Practice Address - Phone:919-920-3923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC58596332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment