Provider Demographics
NPI:1366730269
Name:MCKENNA, THERESA MARY
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARY
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MARY
Other - Last Name:HAYDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:273 NAVARRE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-1041
Mailing Address - Country:US
Mailing Address - Phone:585-489-2874
Mailing Address - Fax:
Practice Address - Street 1:273 NAVARRE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-1041
Practice Address - Country:US
Practice Address - Phone:585-489-2874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260062-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse