Provider Demographics
NPI:1851843114
Name:MCKENZIE, PHILLIP SEAN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:SEAN
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2312
Mailing Address - Country:US
Mailing Address - Phone:304-487-7726
Mailing Address - Fax:304-431-5263
Practice Address - Street 1:122 12TH ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2312
Practice Address - Country:US
Practice Address - Phone:304-487-7726
Practice Address - Fax:304-431-5263
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1851843114363L00000X
WVAPRN60413-FNP-BC363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner