Provider Demographics
NPI:1033627518
Name:MCLENNON, KENISHA
Entity type:Individual
Prefix:
First Name:KENISHA
Middle Name:
Last Name:MCLENNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 JACOBY ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3306
Mailing Address - Country:US
Mailing Address - Phone:862-205-1371
Mailing Address - Fax:
Practice Address - Street 1:276 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2646
Practice Address - Country:US
Practice Address - Phone:973-664-2391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00772600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily