Provider Demographics
NPI:1376753806
Name:MCKENZIE, SHURNET MAY
Entity Type:Individual
Prefix:MS
First Name:SHURNET
Middle Name:MAY
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17012 130TH AVE
Mailing Address - Street 2:APT # 10 H
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3255
Mailing Address - Country:US
Mailing Address - Phone:917-941-6218
Mailing Address - Fax:
Practice Address - Street 1:17012 130TH AVE
Practice Address - Street 2:APT # 10 H
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3255
Practice Address - Country:US
Practice Address - Phone:917-941-6218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY253255164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02500943Medicaid