Provider Demographics
NPI:1942819727
Name:MCKENZIE, NICOLE RENEE (DPT)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:RENEE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 NEEDLE BLVD APT 65
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3334
Mailing Address - Country:US
Mailing Address - Phone:609-284-8664
Mailing Address - Fax:
Practice Address - Street 1:55 NEEDLE BLVD APT 65
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3334
Practice Address - Country:US
Practice Address - Phone:609-284-8664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL35936225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist