Basic Information
| Provider Information | |||||||||
| NPI: | 1942306162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINNEY-BOURNE | ||||||||
| FirstName: | ANGELIQUE | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 CHAMBERS HILL RD | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171112545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175645400 | ||||||||
| FaxNumber: | 7175647859 | ||||||||
| Practice Location | |||||||||
| Address1: | 5400 CHAMBERS HILL RD | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171112545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175645400 | ||||||||
| FaxNumber: | 7175647859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD 418042 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7615520 | 01 | PA | AETNA | OTHER | 1148101 | 01 | PA | HEALTH AMERICA | OTHER | 2147159 | 01 | HIGHMARK PPO | OTHER | 271003587 | 01 | PA | TRICARE | OTHER | 1710213236 | 01 | PA | CD EAST FAMILY HEALTH & WLLNS. CTR. GROUP NPI | OTHER | 177237 | 01 | PA | HIGHMARK MEDICARE | OTHER | 50091367 | 01 | PA | CAPITAL BLUE CROSS | OTHER |