Provider Demographics
NPI:1427617588
Name:MCKINNON, GABRIEL (LPN)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:MCKINNON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14550 GRANDVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2231
Mailing Address - Country:US
Mailing Address - Phone:313-415-6151
Mailing Address - Fax:
Practice Address - Street 1:14550 GRANDVILLE AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2231
Practice Address - Country:US
Practice Address - Phone:313-415-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372500000X, 374U00000X
MI4703114910405300000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No372500000XNursing Service Related ProvidersChore Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703114910Medicaid
MI4703114910OtherBCBS