Healthcare Provider Details

I. General information

NPI: 1952245037
Provider Name (Legal Business Name): MCKENZIE DEE MACMILLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

2 HARROW CT
WENTZVILLE MO
63385-6040
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06261703
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: