MEDICARE: MCKENZIE LYNN STOCK APRN

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	123815	AR
2	363LF0000X	Family Nurse Practitioner	123815	AR

General Provider Information

NPI Number	:	1629817234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKENZIE LYNN STOCK APRN

Provider Business Mailing Address
First Line	:	2203 S PROMENADE BLVD STE 5185
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-8722
Country	:	US
Telephone Number	:	407-552-1035
Fax Number	:

Provider Business Practice Location Address
First Line	:	2203 S PROMENADE BLVD STE 5185
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72758-8722
Country	:	US
Telephone Number	:	407-552-1035
Fax Number	:

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

Provider Enumeration Date	:	05/22/2024
Last Update Date	:	10/23/2024

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