Provider Demographics
NPI:1093209645
Name:GRIFFIN, MAKENZIE RAE (FNP)
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:RAE
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:1340 S 18TH ST STE 204
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4733
Practice Address - Country:US
Practice Address - Phone:904-261-0643
Practice Address - Fax:904-277-4082
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR209597363LF0000X
NY343144363LF0000X
FLAPRN11018528363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR209597OtherFNP LICENSE NO.
NY343144OtherNY FNP LICENSE
NY749697OtherNY RN LICENSE NO.
F01180590OtherAANP