Provider Demographics
NPI:1437119039
Name:MCKENZIE, MELODY LENORE (MD)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:LENORE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:1880 N FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-2687
Practice Address - Country:US
Practice Address - Phone:651-438-1800
Practice Address - Fax:651-438-1837
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN39832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN259024700Medicaid
G57487Medicare UPIN
MN259024700Medicaid