Healthcare Provider Details

I. General information

NPI: 1366366049
Provider Name (Legal Business Name): MCKENZIE WAKEFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FAIRBANKS HALL, 340 WEST 10TH STREET
INDIANAPOLIS IN
46202
US

IV. Provider business mailing address

5510 BOOKER RD
EVANSVILLE IN
47720-2622
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-8157
  • Fax:
Mailing address:
  • Phone: 931-220-2182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: