=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407050164
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA DIANA MCKENZIE CPNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2007
-----------------------------------------------------
Last Update Date | 12/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 PALMER ST STE 1
-----------------------------------------------------
City | CALAIS
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04619-1341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-454-7521
-----------------------------------------------------
Fax | 207-454-3616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 424 WOODLAWN RD
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29646-9163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-244-8380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 3247
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 5003497
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | CNP201420
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------