Provider Demographics
NPI:1902303290
Name:MCKENNA, SUSAN LEE
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LEE
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:LEE
Other - Last Name:LEAVITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 LYTTONSVILLE RD APT 409
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-2236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2730 UNIVERSITY BLVD W
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-1905
Practice Address - Country:US
Practice Address - Phone:301-933-6680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)