Basic Information
| Provider Information | |||||||||
| NPI: | 1770975666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINNON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1910 N CHURCH ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274055666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362747480 | ||||||||
| FaxNumber: | 3362748903 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 N CHURCH ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274055666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362747480 | ||||||||
| FaxNumber: | 3362748903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2015 | ||||||||
| LastUpdateDate: | 03/02/2015 | ||||||||
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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 | 225200000X | A5550 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.