Provider Demographics
NPI:1730124223
Name:MCKANNA, CANDACE KAY (MD)
Entity Type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:KAY
Last Name:MCKANNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1064
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-1064
Mailing Address - Country:US
Mailing Address - Phone:503-754-4557
Mailing Address - Fax:
Practice Address - Street 1:2626 SW BUCKINGHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-3128
Practice Address - Country:US
Practice Address - Phone:503-754-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR109972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000BHKRBMedicare ID - Type Unspecified