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General NPI Number Information
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NPI Number | 1376387472
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Entity Type | Individual
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Provider Name | MCKENNA BLACK PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/24/2024
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Last Update Date | 09/10/2025
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Provider Practice Location Address
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Address Line | 1620 W HARRISON ST
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City | CHICAGO
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State | IL
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Zip | 60612-3801
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Country | US
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Telephone | 312-942-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 3535 OLENTANGY RIVER RD
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City | COLUMBUS
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State | OH
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Zip | 43214-3908
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085.011527
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License Number State | IL
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