Basic Information
| Provider Information | |||||||||
| NPI: | 1336132307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKANNA | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 EAST AVE | ||||||||
| Address2: | SUITE3H | ||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068515721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033546100 | ||||||||
| FaxNumber: | 2033546182 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 116TH AVE NE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254545311 | ||||||||
| FaxNumber: | 4254548188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 10/04/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 254985 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0701700 | 05 | MA | MEDICAID |