Provider Demographics
NPI:1194971051
Name:MCKEVENY, MARY JEAN (RN, MS)
Entity type:Individual
Prefix:
First Name:MARY JEAN
Middle Name:
Last Name:MCKEVENY
Suffix:
Gender:F
Credentials:RN, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WEEKS ST
Mailing Address - Street 2:
Mailing Address - City:BLUE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11715-1516
Mailing Address - Country:US
Mailing Address - Phone:631-363-5735
Mailing Address - Fax:
Practice Address - Street 1:103 W MONTAUK HWY STE 6
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-4003
Practice Address - Country:US
Practice Address - Phone:631-728-0181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY422390-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse