Provider Demographics
NPI:1245801141
Name:DECKER, MCKENZIE JO (DNP)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:JO
Last Name:DECKER
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 OLYMPUS
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-239-3815
Mailing Address - Fax:208-239-3814
Practice Address - Street 1:2850 OLYMPUS
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-239-3815
Practice Address - Fax:208-239-3814
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID58683363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily