Healthcare Provider Details

I. General information

NPI: 1407050164
Provider Name (Legal Business Name): MELISSA DIANA MCKENZIE CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA DIANA MORRIS

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 PALMER ST STE 1
CALAIS ME
04619-1341
US

IV. Provider business mailing address

424 WOODLAWN RD
GREENWOOD SC
29646-9163
US

V. Phone/Fax

Practice location:
  • Phone: 207-454-7521
  • Fax: 207-454-3616
Mailing address:
  • Phone: 828-244-8380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number3247
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5003497
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCNP201420
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: