Healthcare Provider Details

I. General information

NPI: 1417601840
Provider Name (Legal Business Name): MCKENZIE MARY MORCOM CNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 W GEORGIA AVE STE 120
NAMPA ID
83686-6812
US

IV. Provider business mailing address

217 W GEORGIA AVE STE 120
NAMPA ID
83686-6812
US

V. Phone/Fax

Practice location:
  • Phone: 208-498-1760
  • Fax: 208-498-1769
Mailing address:
  • Phone: 208-498-1760
  • Fax: 208-498-1769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number55738
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number55738
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: