Healthcare Provider Details

I. General information

NPI: 1679284905
Provider Name (Legal Business Name): LISA MCKENNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2022
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 W WATERLOO RD
AKRON OH
44319-1116
US

IV. Provider business mailing address

55 W WATERLOO RD
AKRON OH
44319-1116
US

V. Phone/Fax

Practice location:
  • Phone: 330-724-7715
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN-258939
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: