Provider Demographics
NPI:1790177871
Name:ENEBO, MCKENZIE (BSN-RN, PHN)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:ENEBO
Suffix:
Gender:F
Credentials:BSN-RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10752 NESBITT AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-2719
Mailing Address - Country:US
Mailing Address - Phone:952-270-3779
Mailing Address - Fax:
Practice Address - Street 1:10752 NESBITT AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-2719
Practice Address - Country:US
Practice Address - Phone:952-270-3779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 218982-2163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse