Provider Demographics
NPI:1508376401
Name:WATKINS, MCKENZIE ROSE (DPT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:MCKENZIE
Middle Name:ROSE
Last Name:WATKINS
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:STORY
Mailing Address - State:WY
Mailing Address - Zip Code:82842-0098
Mailing Address - Country:US
Mailing Address - Phone:307-680-7695
Mailing Address - Fax:
Practice Address - Street 1:1898 FORT RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-8320
Practice Address - Country:US
Practice Address - Phone:307-672-3473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WY2099225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program