Provider Demographics
NPI:1518418110
Name:MCKENZIE, DIANNE MILLER
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:MILLER
Last Name:MCKENZIE
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 1:181 BLAIRS CT LOT 46
Mailing Address - Street 2:
Mailing Address - City:BLAIRS
Mailing Address - State:VA
Mailing Address - Zip Code:24527-2305
Mailing Address - Country:US
Mailing Address - Phone:434-728-6176
Mailing Address - Fax:434-228-4096
Practice Address - Street 1:181 BLAIRS CT LOT 46
Practice Address - Street 2:
Practice Address - City:BLAIRS
Practice Address - State:VA
Practice Address - Zip Code:24527-2305
Practice Address - Country:US
Practice Address - Phone:434-728-6176
Practice Address - Fax:434-228-4096
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60213383172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver