Provider Demographics
NPI:1962626465
Name:MCKENNA, CARRIE ANNE (RN)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANNE
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:697 N PINECLIFF DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3364
Mailing Address - Country:US
Mailing Address - Phone:928-600-3926
Mailing Address - Fax:
Practice Address - Street 1:3285 E SPARROW AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-7794
Practice Address - Country:US
Practice Address - Phone:928-773-4032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ134661163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool