Healthcare Provider Details

I. General information

NPI: 1245195403
Provider Name (Legal Business Name): MCKENNA SHEA BERGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 DOGWOOD CIR
INMAN SC
29349-9588
US

IV. Provider business mailing address

419 DOGWOOD CIR
INMAN SC
29349-9588
US

V. Phone/Fax

Practice location:
  • Phone: 571-344-2426
  • Fax:
Mailing address:
  • Phone: 571-344-2426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: