Provider Demographics
NPI:1700194958
Name:MCKENNEY, DIANA M (PA)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:M
Last Name:MCKENNEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:I
Other - Last Name:MENDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3700 RT 33
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753
Mailing Address - Country:US
Mailing Address - Phone:732-280-7855
Mailing Address - Fax:732-280-7815
Practice Address - Street 1:3700 ROUTE 33
Practice Address - Street 2:SUITE 101
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753
Practice Address - Country:US
Practice Address - Phone:732-280-7855
Practice Address - Fax:732-280-7815
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00241400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant