MEDICARE: MEAGAN SHASIDY MCKENZIE MHPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1619118676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEAGAN SHASIDY MCKENZIE MHPP

Provider Business Mailing Address
First Line	:	1020 W DAISY BATES DR
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72202-5402
Country	:	US
Telephone Number	:	501-371-9058
Fax Number	:	501-371-9082

Provider Business Practice Location Address
First Line	:	1020 W DAISY BATES DR
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72202-5402
Country	:	US
Telephone Number	:	501-371-9058
Fax Number	:	501-371-9082

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2009
Last Update Date	:	03/20/2009

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