MEDICARE: PATRICIA LENELL MCKINLEY

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	104100000X	Social Worker	8617177	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8617177	OTHER	AZ	DCS/ OLR

General Provider Information

NPI Number	:	1902333875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA LENELL MCKINLEY

Provider Business Mailing Address
First Line	:	PO BOX 16906
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85011-6906
Country	:	US
Telephone Number	:	602-279-1427
Fax Number	:	602-279-1431

Provider Business Practice Location Address
First Line	:	6615 N 17TH AVE APT 3
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-1332
Country	:	US
Telephone Number	:	480-559-7742
Fax Number	:

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

Provider Enumeration Date	:	05/22/2017
Last Update Date	:	05/22/2017

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