Provider Demographics
NPI:1790983823
Name:MCKINNEY, CARRIE L (RD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3318 S CROOKS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47872-7072
Mailing Address - Country:US
Mailing Address - Phone:765-562-2997
Mailing Address - Fax:
Practice Address - Street 1:812 N LOGAN AVE
Practice Address - Street 2:LOGAN CAMPUS
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3752
Practice Address - Country:US
Practice Address - Phone:215-493-4025
Practice Address - Fax:215-493-8039
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered