Healthcare Provider Details

I. General information

NPI: 1093243206
Provider Name (Legal Business Name): KATHLEEN MCKENZIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6372 MECHANICSVILLE TPKE STE 105
MECHANICSVILLE VA
23111-4705
US

IV. Provider business mailing address

6372 MECHANICSVILLE TPKE STE 105
MECHANICSVILLE VA
23111-4705
US

V. Phone/Fax

Practice location:
  • Phone: 804-559-4625
  • Fax: 804-559-4627
Mailing address:
  • Phone: 804-559-4625
  • Fax: 804-559-4627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2101002152
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: