Provider Demographics
NPI:1508416579
Name:BRACE, MCKENZIE
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:BRACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3243 FILLMORE ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2152
Mailing Address - Country:US
Mailing Address - Phone:319-939-8354
Mailing Address - Fax:
Practice Address - Street 1:2820 INGLEWOOD AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4112
Practice Address - Country:US
Practice Address - Phone:914-589-5503
Practice Address - Fax:763-465-0588
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8342363L00000X
MN2375351163WC3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WC3500XNursing Service ProvidersRegistered NurseCardiac Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2375351OtherRN