Provider Demographics
NPI:1689774259
Name:MCKINNIE, MARY JANE (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JANE
Last Name:MCKINNIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-6230
Mailing Address - Country:US
Mailing Address - Phone:337-433-7117
Mailing Address - Fax:337-433-7117
Practice Address - Street 1:905 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-6230
Practice Address - Country:US
Practice Address - Phone:337-433-7117
Practice Address - Fax:337-433-7117
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05000363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1409171Medicaid