Healthcare Provider Details

I. General information

NPI: 1164032462
Provider Name (Legal Business Name): ELIZABETH JEAN MCKENZIE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 SHADY CREST AVE
DEVILLE LA
71328-4000
US

IV. Provider business mailing address

121 SHADY CREST AVE
DEVILLE LA
71328-4000
US

V. Phone/Fax

Practice location:
  • Phone: 318-794-5552
  • Fax:
Mailing address:
  • Phone: 318-794-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number212175
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN144652
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: