Healthcare Provider Details

I. General information

NPI: 1336531409
Provider Name (Legal Business Name): MCKENNA D LOSS PNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MCKENNA WEBB RN

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 07/16/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 W MAIN ST
FAIRFIELD IL
62837-2308
US

IV. Provider business mailing address

PO BOX 155
CHRISTOPHER IL
62822-0155
US

V. Phone/Fax

Practice location:
  • Phone: 618-842-4470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041424762
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number209020289
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: