Healthcare Provider Details

I. General information

NPI: 1699749168
Provider Name (Legal Business Name): WENDI WADE MCKENNA DPT, PCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 10/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5611 PALMER WAY SUITE B
CARLSBAD CA
92010-7253
US

IV. Provider business mailing address

5611 PALMER WAY SUITE B
CARLSBAD CA
92010-7253
US

V. Phone/Fax

Practice location:
  • Phone: 858-442-1094
  • Fax: 760-479-0658
Mailing address:
  • Phone: 858-442-1094
  • Fax: 760-602-8430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number25408
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number70012080
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: