Provider Demographics
NPI:1952332595
Name:MCKENZIE, VANESSA (MD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4899 E SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-6130
Mailing Address - Country:US
Mailing Address - Phone:901-412-4345
Mailing Address - Fax:
Practice Address - Street 1:8990 GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-8532
Practice Address - Country:US
Practice Address - Phone:662-893-1160
Practice Address - Fax:662-893-1166
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45867207R00000X
TN25678207R00000X
MS17796207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN110108905OtherRAILROAD MEDICARE
MS00126757Medicaid
TN3031027OtherBLUE CROSS BLUE SHIELD TN
TN5001948OtherTLC
TN3093293Medicaid
MS00126757Medicaid
TN3093293Medicaid
MS110001847Medicare PIN