Provider Demographics
NPI:1891337267
Name:MCKENNA, MELANY M (PA-C)
Entity Type:Individual
Prefix:
First Name:MELANY
Middle Name:M
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 SPROUL RD FL 3
Mailing Address - Street 2:
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3511
Mailing Address - Country:US
Mailing Address - Phone:610-353-0800
Mailing Address - Fax:
Practice Address - Street 1:2004 SPROUL RD FL 3
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3511
Practice Address - Country:US
Practice Address - Phone:610-353-0800
Practice Address - Fax:610-353-9480
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant