Healthcare Provider Details

I. General information

NPI: 1699597674
Provider Name (Legal Business Name): MCKENZIE OLIVIA COMPTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 10/30/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 W CLINTON ST
GRAY GA
31032-5322
US

IV. Provider business mailing address

427 OLIVER GREENE RD
GRAY GA
31032-5509
US

V. Phone/Fax

Practice location:
  • Phone: 478-221-3075
  • Fax:
Mailing address:
  • Phone: 478-960-3599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN295358
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: