Healthcare Provider Details

I. General information

NPI: 1235828278
Provider Name (Legal Business Name): MCKENZIE SHIRLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 S BROADVIEW ST
CAPE GIRARDEAU MO
63703-5725
US

IV. Provider business mailing address

545 WENTWORTH DR
JACKSON MO
63755-3416
US

V. Phone/Fax

Practice location:
  • Phone: 573-334-4753
  • Fax:
Mailing address:
  • Phone: 901-413-2701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2026024325
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: