Provider Demographics
NPI:1518176320
Name:MCKENNEY, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MCKENNEY
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 1:200 MILL RD STE 180
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5255
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:100 ROSEBROOK WAY
Practice Address - Street 2:
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571-1138
Practice Address - Country:US
Practice Address - Phone:508-273-4901
Practice Address - Fax:508-973-4907
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA253800207Q00000X, 2083B0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110095467AMedicaid