Provider Demographics
NPI:1467820647
Name:MCKENZIE, MAUREEN (MS RDN)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MS RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2182 ARISTA LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 MENDOCINO AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2261
Practice Address - Country:US
Practice Address - Phone:707-393-3506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA630151133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered