Healthcare Provider Details

I. General information

NPI: 1619704087
Provider Name (Legal Business Name): MCKENZIE HOLTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 FAIRMONT BLVD
RAPID CITY SD
57701-7375
US

IV. Provider business mailing address

353 FAIRMONT BLVD
RAPID CITY SD
57701-7375
US

V. Phone/Fax

Practice location:
  • Phone: 605-755-4300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1562
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: