Provider Demographics
NPI:1093254070
Name:CROFT, MCKENZIE
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:CROFT
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 1:13554 SWITZER RD
Mailing Address - Street 2:
Mailing Address - City:FENNIMORE
Mailing Address - State:WI
Mailing Address - Zip Code:53809-9697
Mailing Address - Country:US
Mailing Address - Phone:608-822-5101
Mailing Address - Fax:
Practice Address - Street 1:13554 SWITZER RD
Practice Address - Street 2:
Practice Address - City:FENNIMORE
Practice Address - State:WI
Practice Address - Zip Code:53809
Practice Address - Country:US
Practice Address - Phone:608-822-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3205744164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse