Provider Demographics
NPI:1700190592
Name:MCKENZIE, ROSHUNDIA LYNETTE (FPMHND)
Entity Type:Individual
Prefix:MRS
First Name:ROSHUNDIA
Middle Name:LYNETTE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:FPMHND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 4128
Mailing Address - Street 2:WEST STATION
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39304-4128
Mailing Address - Country:US
Mailing Address - Phone:601-581-7600
Mailing Address - Fax:601-483-5543
Practice Address - Street 1:1818 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-5429
Practice Address - Country:US
Practice Address - Phone:601-581-7600
Practice Address - Fax:601-483-5543
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866095363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05774759Medicaid
MS302I509829Medicare PIN