Healthcare Provider Details

I. General information

NPI: 1881223394
Provider Name (Legal Business Name): NICKESHA ROMAINE MCKENZIE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 PROVIDENCE ST
WEST WARWICK RI
02893-2508
US

IV. Provider business mailing address

1 RIVER ST
WAKEFIELD RI
02879-3214
US

V. Phone/Fax

Practice location:
  • Phone: 401-767-4100
  • Fax:
Mailing address:
  • Phone: 401-767-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCAPRN02290
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberAPRN02290
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9824
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: