Healthcare Provider Details

I. General information

NPI: 1568869279
Provider Name (Legal Business Name): MCKENZIE LEE MYERS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MCKENZIE LEE LEIKAM

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

537 UNION AVE
GRANTS PASS OR
97527-5543
US

IV. Provider business mailing address

2620 E BARNETT RD STE H
MEDFORD OR
97504-8383
US

V. Phone/Fax

Practice location:
  • Phone: 541-507-2020
  • Fax: 541-955-5105
Mailing address:
  • Phone: 541-789-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-76380-011
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: