Basic Information
| Provider Information | |||||||||
| NPI: | 1780710509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKENNA | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CDOE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 CLEMENT ST | ||||||||
| Address2: | |||||||||
| City: | NORTH PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029043212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017265615 | ||||||||
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| Practice Location | |||||||||
| Address1: | 455 TOLL GATE RD | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028862759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017377000 | ||||||||
| FaxNumber: | 4017364212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 133V00000X | 28547 | RI | X | Dietary & Nutritional Service Providers | Dietitian, Registered | 163W00000X | 28547 | RI | X | Nursing Service Providers | Registered Nurse |
No ID Information.