Provider Demographics
NPI:1003436585
Name:ABBOTT, MAKENZIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:LYNN
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 KIDWELL DR
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:MO
Mailing Address - Zip Code:65084-1784
Mailing Address - Country:US
Mailing Address - Phone:573-378-4666
Mailing Address - Fax:
Practice Address - Street 1:901 KIDWELL DR
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084-1784
Practice Address - Country:US
Practice Address - Phone:573-378-4666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020007089363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant