Healthcare Provider Details

I. General information

NPI: 1912407032
Provider Name (Legal Business Name): MCKENZIE ANNE MATLOCK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 04/14/2026
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S NATIONAL AVE DIV PED HOSPITALIST MED
SPRINGFIELD MO
65807-5210
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-7728
  • Fax: 417-269-7729
Mailing address:
  • Phone: 417-269-7728
  • Fax: 417-269-7729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2018003866
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: