Healthcare Provider Details

I. General information

NPI: 1275821316
Provider Name (Legal Business Name): MEKENZIE SPENCER JOHNSTON KMACK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEKENZIE SPENCER JOHNSTON CRNA

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 SW ABBEY ST
NEWPORT OR
97365-4820
US

IV. Provider business mailing address

313 SE 116TH ST
SOUTH BEACH OR
97366-9729
US

V. Phone/Fax

Practice location:
  • Phone: 541-265-2244
  • Fax: 541-574-1838
Mailing address:
  • Phone: 206-399-3404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD127901
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: