Provider Demographics
NPI:1043702624
Name:WEST, MCKENZIE ANN
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:ANN
Last Name:WEST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 ORANGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-3956
Mailing Address - Country:US
Mailing Address - Phone:404-545-2616
Mailing Address - Fax:
Practice Address - Street 1:306 STATION 22 1/2 ST
Practice Address - Street 2:
Practice Address - City:SULLIVANS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29482
Practice Address - Country:US
Practice Address - Phone:843-883-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant