Provider Demographics
NPI:1275155228
Name:MCKENZIE, PAM A (NCTMB)
Entity Type:Individual
Prefix:
First Name:PAM
Middle Name:A
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61057 CHAMOMILE PL
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9168
Mailing Address - Country:US
Mailing Address - Phone:562-706-8208
Mailing Address - Fax:
Practice Address - Street 1:224 SE MILLER AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1304
Practice Address - Country:US
Practice Address - Phone:541-306-0988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21675225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist