Provider Demographics
NPI:1760410609
Name:MCKENNA, MICHELE ELIZABETH (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:ELIZABETH
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 N HORNE UNIT 90
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-3675
Mailing Address - Country:US
Mailing Address - Phone:480-280-9577
Mailing Address - Fax:
Practice Address - Street 1:967 N MCQUEEN RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225
Practice Address - Country:US
Practice Address - Phone:480-726-3445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003067152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200449680AMedicaid
IN200449680AMedicaid