Provider Demographics
NPI:1164119160
Name:ELLETT, MCKENZIE REE (NP)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:REE
Last Name:ELLETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:LOA
Mailing Address - State:UT
Mailing Address - Zip Code:84747-0397
Mailing Address - Country:US
Mailing Address - Phone:435-491-2906
Mailing Address - Fax:
Practice Address - Street 1:128 S 300 W
Practice Address - Street 2:
Practice Address - City:BICKNELL
Practice Address - State:UT
Practice Address - Zip Code:84715-7722
Practice Address - Country:US
Practice Address - Phone:435-425-3744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9197962-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily