Provider Demographics
NPI:1407050164
Name:MCKENZIE, MELISSA DIANA (CPNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANA
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:DIANA
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:424 WOODLAWN RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-9163
Mailing Address - Country:US
Mailing Address - Phone:828-244-8380
Mailing Address - Fax:
Practice Address - Street 1:37 PALMER ST STE 1
Practice Address - Street 2:
Practice Address - City:CALAIS
Practice Address - State:ME
Practice Address - Zip Code:04619-1341
Practice Address - Country:US
Practice Address - Phone:207-454-7521
Practice Address - Fax:207-454-3616
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3247363LP0200X
NC5003497363LP0200X
MECNP201420363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCL446H895OtherMEDICARE PIN
SCNP3680Medicaid