Provider Demographics
NPI:1780710509
Name:MCKENNA, JANICE M (CDOE)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:M
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:CDOE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CLEMENT ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-3212
Mailing Address - Country:US
Mailing Address - Phone:401-726-5615
Mailing Address - Fax:
Practice Address - Street 1:455 TOLL GATE RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2759
Practice Address - Country:US
Practice Address - Phone:401-737-7000
Practice Address - Fax:401-736-4212
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI28547133V00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI00000000000Medicare ID - Type UnspecifiedPENDING
RI00000000000Medicare UPIN