Provider Demographics
NPI:1013265560
Name:MCKENNA, EILEEN (RD, CDN)
Entity Type:Individual
Prefix:MRS
First Name:EILEEN
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HORTON ST
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-1513
Mailing Address - Country:US
Mailing Address - Phone:516-812-5453
Mailing Address - Fax:
Practice Address - Street 1:110 HORTON ST
Practice Address - Street 2:
Practice Address - City:MALVERNE
Practice Address - State:NY
Practice Address - Zip Code:11565-1513
Practice Address - Country:US
Practice Address - Phone:516-812-5453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004863-1133N00000X
NY714429133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist