Provider Demographics
NPI:1396577755
Name:SPRAGUE, MCKENZIE MARIE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:MARIE
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 W PRESCOTT ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33616-2903
Mailing Address - Country:US
Mailing Address - Phone:518-572-8781
Mailing Address - Fax:
Practice Address - Street 1:4950 W PRESCOTT ST UNIT 12307
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33616-2979
Practice Address - Country:US
Practice Address - Phone:518-572-8781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY818447363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily