Provider Demographics
NPI:1366552614
Name:MCKENNA, LISA BETH (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:BETH
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1387 LINCOLNSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-3392
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 W SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-5646
Practice Address - Country:US
Practice Address - Phone:312-666-3494
Practice Address - Fax:773-276-0749
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036079925208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE73679Medicare UPIN