Provider Demographics
NPI:1881445534
Name:MCKINNEY, WILLIE CLARENCE
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:CLARENCE
Last Name:MCKINNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11278 STIRTON DR
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-2390
Mailing Address - Country:US
Mailing Address - Phone:469-271-8649
Mailing Address - Fax:
Practice Address - Street 1:11278 STIRTON DR
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-2390
Practice Address - Country:US
Practice Address - Phone:469-271-8649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36274279343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)