Provider Demographics
NPI:1295925089
Name:MCKENZIE, ILA LEIGH (NP)
Entity type:Individual
Prefix:
First Name:ILA
Middle Name:LEIGH
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LEIGH
Other - Middle Name:
Other - Last Name:COLLINS MCKENZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 S B B KING BLVD # 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:901-436-1381
Mailing Address - Fax:
Practice Address - Street 1:4700 SANDOZ DR
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-8143
Practice Address - Country:US
Practice Address - Phone:252-234-2436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0050-03231363L00000X
NC5003231363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2593026Medicare PIN