MEDICARE: MADELYN STELLA MCKENNAN FAMILY NURSE PRACTIT

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	363LF0000X	Family Nurse Practitioner	APN.0991240	CO

General Provider Information

NPI Number	:	1821044983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELYN STELLA MCKENNAN FAMILY NURSE PRACTIT

Provider Business Mailing Address
First Line	:	3205 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-5147
Country	:	US
Telephone Number	:	719-776-3216
Fax Number	:	719-776-3220

Provider Business Practice Location Address
First Line	:	230 STONEBECK LN
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-7982
Country	:	US
Telephone Number	:	253-820-9953
Fax Number	:

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

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	07/15/2016

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