Provider Demographics
NPI:1861629545
Name:MCKENNA, MARY ANNE (MSED)
Entity Type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 PARK LN
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12528-2824
Mailing Address - Country:US
Mailing Address - Phone:845-883-5151
Mailing Address - Fax:845-883-6452
Practice Address - Street 1:40 PARK LN
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:NY
Practice Address - Zip Code:12528-2824
Practice Address - Country:US
Practice Address - Phone:845-883-5151
Practice Address - Fax:845-883-6452
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist