Healthcare Provider Details

I. General information

NPI: 1598081614
Provider Name (Legal Business Name): ISSEL MARIE MCKENZIE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2010
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 LAKE WRIGHT DR SUITE 101
NORFOLK VA
23502-1859
US

IV. Provider business mailing address

5700 LAKE WRIGHT DR SUITE 101
NORFOLK VA
23502-1859
US

V. Phone/Fax

Practice location:
  • Phone: 757-502-4840
  • Fax: 757-502-4841
Mailing address:
  • Phone: 757-502-4840
  • Fax: 757-502-4841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024168353
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: