Healthcare Provider Details

I. General information

NPI: 1205896958
Provider Name (Legal Business Name): SUSAN RUTH MCKINLEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EMANCIPATION DR
HAMPTON VA
23667-0001
US

IV. Provider business mailing address

6118 LYNDHURST AVE
NORFOLK VA
23502-5311
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-9961
  • Fax:
Mailing address:
  • Phone: 757-466-7544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001058809
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: