Provider Demographics
NPI:1235595604
Name:MCKINNON, EDYN
Entity type:Individual
Prefix:
First Name:EDYN
Middle Name:
Last Name:MCKINNON
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 1:3950 GA HIGHWAY 64 E
Mailing Address - Street 2:
Mailing Address - City:AXSON
Mailing Address - State:GA
Mailing Address - Zip Code:31624-2032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3950 GA HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:AXSON
Practice Address - State:GA
Practice Address - Zip Code:31624-2032
Practice Address - Country:US
Practice Address - Phone:912-592-3152
Practice Address - Fax:628-246-8299
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN216659363LF0000X, 363LP0808X
FL11021035363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily