Provider Demographics
NPI:1679772859
Name:MCKINNEY, KIERSTEN M (PTA)
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:M
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66350 US HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46536-9769
Mailing Address - Country:US
Mailing Address - Phone:574-360-5314
Mailing Address - Fax:
Practice Address - Street 1:2600 MOREHOUSE AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-2552
Practice Address - Country:US
Practice Address - Phone:574-295-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003696A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant