Provider Demographics
NPI:1154063287
Name:MCKENZIE, TYWONA (LPN)
Entity Type:Individual
Prefix:
First Name:TYWONA
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 BARRINGTON VW
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-1846
Mailing Address - Country:US
Mailing Address - Phone:678-582-9317
Mailing Address - Fax:
Practice Address - Street 1:1607 BARRINGTON VW
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-1846
Practice Address - Country:US
Practice Address - Phone:678-582-9317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-09
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0002100838164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003258912AMedicaid