Provider Demographics
NPI:1689345340
Name:MCKINNON, CARMEN LETESSIA
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:LETESSIA
Last Name:MCKINNON
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 1:1275 MIXON SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-6194
Mailing Address - Country:US
Mailing Address - Phone:334-718-7030
Mailing Address - Fax:334-983-5191
Practice Address - Street 1:1275 MIXON SCHOOL RD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-6194
Practice Address - Country:US
Practice Address - Phone:334-718-7030
Practice Address - Fax:334-983-5191
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2021-2329251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1811446263OtherNPPES