MEDICARE: MRS. RAFFAELA MCKENNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency	708393131	NY

General Provider Information

NPI Number	:	1578942710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RAFFAELA MCKENNA

Provider Business Mailing Address
First Line	:	6011 76TH ST
Second Line	:
City	:	MIDDLE VILLAGE
State	:	NY
Zip	:	11379-5227
Country	:	US
Telephone Number	:	646-596-6211
Fax Number	:

Provider Business Practice Location Address
First Line	:	6011 76TH ST
Second Line	:
City	:	MIDDLE VILLAGE
State	:	NY
Zip	:	11379-5227
Country	:	US
Telephone Number	:	646-596-6211
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2015
Last Update Date	:	05/20/2015

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