MEDICARE: DR. WENDI WADE MCKENNA DPT, PCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	25408	CA
2	2251P0200X	Pediatric Physical Therapist	70012080	IL

General Provider Information

NPI Number	:	1699749168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WENDI WADE MCKENNA DPT, PCS

Provider Business Mailing Address
First Line	:	5611 PALMER WAY
Second Line	:	SUITE B
City	:	CARLSBAD
State	:	CA
Zip	:	92010-7253
Country	:	US
Telephone Number	:	858-442-1094
Fax Number	:	760-602-8430

Provider Business Practice Location Address
First Line	:	5611 PALMER WAY
Second Line	:	SUITE B
City	:	CARLSBAD
State	:	CA
Zip	:	92010-7253
Country	:	US
Telephone Number	:	858-442-1094
Fax Number	:	760-479-0658

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2006
Last Update Date	:	10/15/2009

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