Provider Demographics
NPI:1508257858
Name:MCKENZIE, IRENE MARIA (APN, CPNP)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:MARIA
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:APN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 MICHIGAN ST NE STE 5201
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2530
Practice Address - Country:US
Practice Address - Phone:616-486-5885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704279748363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics