Provider Demographics
NPI:1396872164
Name:MCKINNEY, GWENDOLYN K (CRNA)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:K
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5859 E MIDWICK LN
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-5528
Mailing Address - Country:US
Mailing Address - Phone:909-946-5752
Mailing Address - Fax:
Practice Address - Street 1:5859 E MIDWICK LN
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-5528
Practice Address - Country:US
Practice Address - Phone:909-946-5752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1394367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ23578ZMedicare ID - Type Unspecified