Healthcare Provider Details

I. General information

NPI: 1699384990
Provider Name (Legal Business Name): MCKENZIE KENNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 E LAKE ST
MCCALL ID
83638-3811
US

IV. Provider business mailing address

2053 RIVERCREST DR APT 306
TWIN FALLS ID
83301-3090
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-2433
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE42533
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: