Provider Demographics
NPI:1639701295
Name:MOWERY, MCKENZIE D
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:D
Last Name:MOWERY
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 1:1402 N CHOCTAW PL
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-3114
Mailing Address - Country:US
Mailing Address - Phone:918-798-9144
Mailing Address - Fax:
Practice Address - Street 1:1402 N CHOCTAW PL
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3114
Practice Address - Country:US
Practice Address - Phone:918-798-9144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist