Healthcare Provider Details

I. General information

NPI: 1275467805
Provider Name (Legal Business Name): MCKENZIE MAXSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304-1227
US

IV. Provider business mailing address

79 28TH ST
HUNTINGTON WV
25702-1153
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5432
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number105271
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: