Provider Demographics
NPI:1265464226
Name:MCKENZIE, MICHAEL B (ARNP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:B
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19611 SR 20 W
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-3917
Mailing Address - Country:US
Mailing Address - Phone:850-674-5645
Mailing Address - Fax:850-674-5420
Practice Address - Street 1:19611 SR 20 W
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-3917
Practice Address - Country:US
Practice Address - Phone:850-674-5645
Practice Address - Fax:850-674-5420
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1486662363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL027949891Medicaid