Provider Demographics
NPI:1770192304
Name:MCKINLEY, ROBERTA S (CSA)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:S
Last Name:MCKINLEY
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 CARRBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-1105
Mailing Address - Country:US
Mailing Address - Phone:614-657-3405
Mailing Address - Fax:
Practice Address - Street 1:5955 CARRBRIDGE CT
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:OH
Practice Address - Zip Code:43119-1105
Practice Address - Country:US
Practice Address - Phone:614-657-3405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC-1692086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty