Provider Demographics
NPI:1144495250
Name:MCKENNA, KELLY A (NP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:A
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:MANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:6 FOUNTAIN PLZ
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-2211
Mailing Address - Country:US
Mailing Address - Phone:716-691-8838
Mailing Address - Fax:716-564-1134
Practice Address - Street 1:8270 COLLEGE PKWY STE 130
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-5107
Practice Address - Country:US
Practice Address - Phone:239-322-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY507916-1163W00000X
NY304842207P00000X
NYF304842-1363LA2200X
FLAPRN11011642363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health