MEDICARE: CRYSTAL NICOLE MCKENZIE MSN, RN, CPNP

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	363LP0200X	Pediatric Nurse Practitioner	14710	OH

General Provider Information

NPI Number	:	1619153806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL NICOLE MCKENZIE MSN, RN, CPNP

Provider Business Mailing Address
First Line	:	2865 W BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43204-2643
Country	:	US
Telephone Number	:	614-531-9277
Fax Number	:

Provider Business Practice Location Address
First Line	:	2865 W BROAD ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43204-2643
Country	:	US
Telephone Number	:	614-531-9277
Fax Number	:

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

Provider Enumeration Date	:	01/17/2008
Last Update Date	:	07/12/2013

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