Provider Demographics
NPI:1467021527
Name:MCKENZIE, VENDETTA (AGNP-BC)
Entity Type:Individual
Prefix:
First Name:VENDETTA
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BEAR SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18302-9402
Mailing Address - Country:US
Mailing Address - Phone:347-564-3866
Mailing Address - Fax:
Practice Address - Street 1:1000 BEAR SWAMP RD
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18302-9402
Practice Address - Country:US
Practice Address - Phone:347-564-3866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309891363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology