Basic Information
| Provider Information | |||||||||
| NPI: | 1639281272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKENNA | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028472415 | ||||||||
| FaxNumber: | 8028475324 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 COLCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028472415 | ||||||||
| FaxNumber: | 8028475324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 04/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 4646 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367H00000X | 135.0000038 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.