Basic Information
| Provider Information | |||||||||
| NPI: | 1225411002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINNIES | ||||||||
| FirstName: | EBONY | ||||||||
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| Credential: | M,D, | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5478 | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703025478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854934544 | ||||||||
| FaxNumber: | 9854492513 | ||||||||
| Practice Location | |||||||||
| Address1: | 726 N ACADIA RD STE 2300 | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703015078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854933090 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 10/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 324523 | LA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.