Healthcare Provider Details

I. General information

NPI: 1609109578
Provider Name (Legal Business Name): DEANNA MARIE MCKINNEY RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S JACKSON ST
IOLA WI
54945-9626
US

IV. Provider business mailing address

PO BOX 446 310 S JACKSON ST
IOLA WI
54945-0446
US

V. Phone/Fax

Practice location:
  • Phone: 715-445-4321
  • Fax:
Mailing address:
  • Phone: 715-445-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number5852-16
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: