Provider Demographics
NPI:1093497810
Name:CARPENTER-LOTT, MYKENZIE
Entity Type:Individual
Prefix:
First Name:MYKENZIE
Middle Name:
Last Name:CARPENTER-LOTT
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 1:176 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-2369
Mailing Address - Country:US
Mailing Address - Phone:307-851-8247
Mailing Address - Fax:
Practice Address - Street 1:176 WASHINGTON STREET
Practice Address - Street 2:176
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520
Practice Address - Country:US
Practice Address - Phone:307-851-8247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator