Provider Demographics
NPI:1023071610
Name:MCKENNA, DENA D (PAAA)
Entity type:Individual
Prefix:MRS
First Name:DENA
Middle Name:D
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:PAAA
Other - Prefix:MISS
Other - First Name:DENA
Other - Middle Name:
Other - Last Name:GOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAAA
Mailing Address - Street 1:777 HEMLOCK ST
Mailing Address - Street 2:MSC10
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2102
Mailing Address - Country:US
Mailing Address - Phone:478-633-1000
Mailing Address - Fax:
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:MSC10
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-633-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003508367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001165CMedicaid
GA003508OtherGA LIC NUMBER