MEDICARE: MELISSA DIANA MCKENZIE CPNP

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	363LP0200X	Pediatric Nurse Practitioner	3247	SC
2	363LP0200X	Pediatric Nurse Practitioner	5003497	NC
3	363LP0200X	Pediatric Nurse Practitioner	CNP201420	ME

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SCL446H895	OTHER	SC	MEDICARE PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407050164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA DIANA MCKENZIE CPNP

Provider Business Mailing Address
First Line	:	424 WOODLAWN RD
Second Line	:
City	:	GREENWOOD
State	:	SC
Zip	:	29646-9163
Country	:	US
Telephone Number	:	828-244-8380
Fax Number	:

Provider Business Practice Location Address
First Line	:	37 PALMER ST STE 1
Second Line	:
City	:	CALAIS
State	:	ME
Zip	:	04619-1341
Country	:	US
Telephone Number	:	207-454-7521
Fax Number	:	207-454-3616

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

Provider Enumeration Date	:	06/14/2007
Last Update Date	:	12/01/2021

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