Provider Demographics
NPI:1073119277
Name:HALE, MAKENZIE NICHOLE
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:NICHOLE
Last Name:HALE
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:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:SOPHIA
Mailing Address - State:WV
Mailing Address - Zip Code:25921-1449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 MAPLE ST
Practice Address - Street 2:402
Practice Address - City:SOPHIA
Practice Address - State:WV
Practice Address - Zip Code:25921
Practice Address - Country:US
Practice Address - Phone:304-994-0203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00301466781Medicaid