Provider Demographics
NPI:1679110332
Name:MCKENNA, CHARLES JAMES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JAMES
Last Name:MCKENNA
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 1:8904 QUARRY RIDGE TRAIL
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76244
Mailing Address - Country:US
Mailing Address - Phone:361-815-3393
Mailing Address - Fax:
Practice Address - Street 1:6124 W PARKER RD STE 530
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8140
Practice Address - Country:US
Practice Address - Phone:214-778-1075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141458363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care