Provider Demographics
NPI:1326620246
Name:WARDWELL, MCKENZIE D (FNP-C)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:D
Last Name:WARDWELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 CALHOUN ST STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-3536
Mailing Address - Country:US
Mailing Address - Phone:843-235-1060
Mailing Address - Fax:
Practice Address - Street 1:49 CALHOUN ST STE A
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-3536
Practice Address - Country:US
Practice Address - Phone:843-235-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY347600363LF0000X
MARN2332554363LF0000X
SC25838363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily