Provider Demographics
NPI:1740170489
Name:KOLSTAD, MCKENZIE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:KOLSTAD
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 1:1 OLD FERRY RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-2923
Mailing Address - Country:US
Mailing Address - Phone:480-586-5841
Mailing Address - Fax:
Practice Address - Street 1:513 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-1471
Practice Address - Country:US
Practice Address - Phone:401-324-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-05
Last Update Date:2025-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program