Provider Demographics
NPI:1225782428
Name:BENNETT, MCKENZIE JOLIE ANN (LDO)
Entity Type:Individual
Prefix:MS
First Name:MCKENZIE
Middle Name:JOLIE ANN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SLEATER KINNEY RD SE STE E
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1113
Mailing Address - Country:US
Mailing Address - Phone:253-209-4295
Mailing Address - Fax:
Practice Address - Street 1:700 SLEATER KINNEY RD SE STE E
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1113
Practice Address - Country:US
Practice Address - Phone:253-209-4295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60389139156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADO60389139OtherDISPENSING OPTICIANS LICENSE