MEDICARE: MCKENZIE BLACK RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	220643	OK

General Provider Information

NPI Number	:	1093652620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKENZIE BLACK RN

Provider Business Mailing Address
First Line	:	1201 NW FORT SILL BLVD
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73507-5446
Country	:	US
Telephone Number	:	580-355-8544
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 NW FORT SILL BLVD
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73507-5446
Country	:	US
Telephone Number	:	580-355-8544
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2026
Last Update Date	:	05/01/2026

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Directions to “ MCKENZIE BLACK RN” Practice Location

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