Provider Demographics
NPI:1053957936
Name:MEDDERS, MCKENNA (ATC)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:MEDDERS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:75457-0479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:523 HWY 37 S
Practice Address - Street 2:
Practice Address - City:MT. VERNON
Practice Address - State:TX
Practice Address - Zip Code:75457
Practice Address - Country:US
Practice Address - Phone:903-563-5544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer