Provider Demographics
NPI:1043739428
Name:MCKENZIE, CAROL ELIZABETH (INTERN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ELIZABETH
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 OSHAUGHNESSY ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1329
Mailing Address - Country:US
Mailing Address - Phone:406-240-6674
Mailing Address - Fax:
Practice Address - Street 1:2705 OSHAUGHNESSY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808
Practice Address - Country:US
Practice Address - Phone:406-240-6674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program