MEDICARE: PRINCESS MCKENZIE

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	95016485	CA

General Provider Information

NPI Number	:	1639763808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRINCESS MCKENZIE

Provider Business Mailing Address
First Line	:	5455 WILSHIRE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-4201
Country	:	US
Telephone Number	:	323-639-5488
Fax Number	:

Provider Business Practice Location Address
First Line	:	5455 WILSHIRE BLVD STE 903
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-4236
Country	:	US
Telephone Number	:	844-867-8444
Fax Number	:

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

Provider Enumeration Date	:	02/26/2021
Last Update Date	:	08/01/2023

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Directions to “ PRINCESS MCKENZIE ” Practice Location

Language	Start Address	Practice Location

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