Healthcare Provider Details

I. General information

NPI: 1497754642
Provider Name (Legal Business Name): VICKY L TAYLOR-MCKENNA A.P.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. VICKY LYNNE TAYLOR MCKENNA

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17201 I H 45 S
SHENANDOAH TX
77385-3311
US

IV. Provider business mailing address

17201 I H 45 S
SHENANDOAH TX
77385-3311
US

V. Phone/Fax

Practice location:
  • Phone: 936-270-2099
  • Fax:
Mailing address:
  • Phone: 936-270-2099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number564468
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP112768
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: