Provider Demographics
NPI:1992963862
Name:MCKINNEY, ELYSSA MARIE (DO)
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:MARIE
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 WRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-1623
Mailing Address - Country:US
Mailing Address - Phone:859-605-6480
Mailing Address - Fax:
Practice Address - Street 1:640 WRIGHT AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-1623
Practice Address - Country:US
Practice Address - Phone:859-605-6480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY03223208D00000X
KY9543122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY113390Medicare PIN