Provider Demographics
NPI:1669674750
Name:MCKENNA, MAUREEN LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:LYNNE
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAUREEN
Other - Middle Name:LYNNE
Other - Last Name:BOWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:176 TOLL GATE RD
Mailing Address - Street 2:STE 101
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-4479
Mailing Address - Country:US
Mailing Address - Phone:401-737-9240
Mailing Address - Fax:401-739-6413
Practice Address - Street 1:176 TOLL GATE RD STE 101
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4479
Practice Address - Country:US
Practice Address - Phone:401-737-9240
Practice Address - Fax:401-739-6413
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD18272208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMD18272OtherLICENSE