Healthcare Provider Details

I. General information

NPI: 1861538654
Provider Name (Legal Business Name): PATRICIA FLYNN MCKENZIE B.C, A.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD PRIMARY CARE SERVICE LINE
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

16134 BARRIER REEF CT
GROVER MO
63040-1815
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 636-527-0758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number143563
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: