Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 036097698 | IL |
NPI | 1003818550 |
---|---|
Provider Name | Valerie D Mckenna |
First Address | Lombard, IL 60148-6110 |
Second Address | Melrose Park, IL 60160-4039 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2005 |
Last Update Date | 17/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G99211 | (02) | IL |