Provider Demographics
NPI:1821769878
Name:MCKENZIE, LATISHA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:LATISHA
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 OLD SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:39854-4627
Mailing Address - Country:US
Mailing Address - Phone:229-334-9353
Mailing Address - Fax:
Practice Address - Street 1:23 OLD SCHOOL RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:GA
Practice Address - Zip Code:39854-4627
Practice Address - Country:US
Practice Address - Phone:229-334-9353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP001043363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily