Basic Information
| Provider Information | |||||||||
| NPI: | 1225287121 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKINLEY | ||||||||
| FirstName: | SIDNEY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4864 JACKSON ST | ||||||||
| Address2: | MED 3 CLINIC | ||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712026400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183307626 | ||||||||
| FaxNumber: | 3183307648 | ||||||||
| Practice Location | |||||||||
| Address1: | 4864 JACKSON ST | ||||||||
| Address2: | MED 3 CLINIC | ||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712026400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183307626 | ||||||||
| FaxNumber: | 3183307648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2008 | ||||||||
| LastUpdateDate: | 08/10/2010 | ||||||||
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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 | 363LF0000X | 05599 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 020914 | 01 | LA | LOUISIANA STATE BOARD OF NURSING PERSCRIPTIVE AUTHORITY | OTHER | 05599 | 01 | LA | ADVANCED PRACTICE | OTHER | 096467 | 01 | LA | RN | OTHER | 34884 | 05 | LA | MEDICAID |