Provider Demographics
NPI:1174299325
Name:MCKENNELL, MADELINE ROSE (PT, DPT)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:ROSE
Last Name:MCKENNELL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11722 ARMADA WAY
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-1802
Mailing Address - Country:US
Mailing Address - Phone:920-680-2817
Mailing Address - Fax:
Practice Address - Street 1:1630 S TUTTLE AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3108
Practice Address - Country:US
Practice Address - Phone:941-556-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL37662225100000X, 2251X0800X
2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic