Provider Demographics
NPI:1881493070
Name:ROMANELLI, MCKENNA
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:ROMANELLI
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 1:2070 GREEN BAY RD STE 163
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 GENEVA PKWY N STE 100
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4562
Practice Address - Country:US
Practice Address - Phone:262-299-6199
Practice Address - Fax:262-293-6953
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16449-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner