Provider Demographics
NPI:1154674638
Name:MCKENZIE, AUDREY E (PTA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:E
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10896 POBLADO RD
Mailing Address - Street 2:1322
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5325
Mailing Address - Country:US
Mailing Address - Phone:858-877-0647
Mailing Address - Fax:858-705-6108
Practice Address - Street 1:10896 POBLADO RD
Practice Address - Street 2:1322
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-5325
Practice Address - Country:US
Practice Address - Phone:858-877-0647
Practice Address - Fax:858-705-6108
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-20
Last Update Date:2012-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 2987225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist