Provider Demographics
NPI:1588322465
Name:MCKANNA, SALLY MARTHA
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:MARTHA
Last Name:MCKANNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 COUNTY ROAD 425 E
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:IL
Mailing Address - Zip Code:61548-7835
Mailing Address - Country:US
Mailing Address - Phone:815-263-2517
Mailing Address - Fax:
Practice Address - Street 1:5533 N GALENA RD
Practice Address - Street 2:
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-4447
Practice Address - Country:US
Practice Address - Phone:309-682-5428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004478225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant