Healthcare Provider Details

I. General information

NPI: 1477856466
Provider Name (Legal Business Name): JOY C MCKENNA APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 12/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MAPLE RD
JOLIET IL
60432-1439
US

IV. Provider business mailing address

4821 W 106TH ST
OAK LAWN IL
60453-5232
US

V. Phone/Fax

Practice location:
  • Phone: 815-740-1100
  • Fax:
Mailing address:
  • Phone: 708-217-6548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.008507
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: