Provider Demographics
NPI:1669017331
Name:MCKENNA, ADRIA MARIE
Entity Type:Individual
Prefix:
First Name:ADRIA
Middle Name:MARIE
Last Name:MCKENNA
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 1:5028 CLAYRIDGE DR APT 309
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1251
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5028 CLAYRIDGE DR APT 309
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1251
Practice Address - Country:US
Practice Address - Phone:314-354-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-16
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO3747A0650X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider