Provider Demographics
NPI:1902416134
Name:MCKENNA, KATHRYN F (NP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:F
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 GODFREY RD STE B
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-2741
Mailing Address - Country:US
Mailing Address - Phone:618-463-7800
Mailing Address - Fax:
Practice Address - Street 1:5520 GODFREY RD STE B
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2741
Practice Address - Country:US
Practice Address - Phone:618-463-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.021685363LF0000X
IL209021685363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily