Provider Demographics
NPI:1558018879
Name:MCKAY, MAXIE
Entity Type:Individual
Prefix:
First Name:MAXIE
Middle Name:
Last Name:MCKAY
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 1:177 W PRICE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4345
Mailing Address - Country:US
Mailing Address - Phone:385-315-1048
Mailing Address - Fax:
Practice Address - Street 1:634 E ANGIE CIR
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1354
Practice Address - Country:US
Practice Address - Phone:385-529-3508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT155866502Medicaid