Healthcare Provider Details

I. General information

NPI: 1063292233
Provider Name (Legal Business Name): RENATTO DIEAGO MCKENZIE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 SMYTH RD
MANCHESTER NH
03104-7007
US

IV. Provider business mailing address

27 BLUEBERRY LN
LYNDEBOROUGH NH
03082-5617
US

V. Phone/Fax

Practice location:
  • Phone: 603-624-4366
  • Fax:
Mailing address:
  • Phone: 603-438-3623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN2297979
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number069566-21
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: