Healthcare Provider Details

I. General information

NPI: 1992963862
Provider Name (Legal Business Name): ELYSSA MARIE MCKINNEY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 WRIGHT AVE
BOWLING GREEN KY
42103-1623
US

IV. Provider business mailing address

640 WRIGHT AVE
BOWLING GREEN KY
42103-1623
US

V. Phone/Fax

Practice location:
  • Phone: 859-605-6480
  • Fax:
Mailing address:
  • Phone: 859-605-6480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number9543
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number03223
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: