Provider Demographics
NPI:1841832391
Name:MCKENNA, ALIX REBECCA WILDER (APRN)
Entity type:Individual
Prefix:
First Name:ALIX
Middle Name:REBECCA WILDER
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 BERNDALE DR
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880
Mailing Address - Country:US
Mailing Address - Phone:858-449-9037
Mailing Address - Fax:
Practice Address - Street 1:800 HOWARD AVENUE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519
Practice Address - Country:US
Practice Address - Phone:877-925-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT147866163W00000X
CT8596363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse