Provider Demographics
NPI:1790051548
Name:MCKINNON, WENDY (APN)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:APN
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 610393
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75261-0393
Mailing Address - Country:US
Mailing Address - Phone:903-757-6042
Mailing Address - Fax:903-232-8226
Practice Address - Street 1:701 E MARSHALL AVE STE 309
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5597
Practice Address - Country:US
Practice Address - Phone:903-315-2744
Practice Address - Fax:903-234-1339
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP121666363L00000X, 363LW0102X
TX648633363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX303491003Medicaid