Provider Demographics
NPI:1457582009
Name:MCKENZIE, SUSAN GARBOTZ (ARNP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:GARBOTZ
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:4821 US HWY 98 W
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459
Mailing Address - Country:US
Mailing Address - Phone:850-622-2055
Mailing Address - Fax:850-622-2053
Practice Address - Street 1:4821 US HWY 98 W
Practice Address - Street 2:SUITE 104
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459
Practice Address - Country:US
Practice Address - Phone:850-622-2055
Practice Address - Fax:850-622-2053
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9369453163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0L03OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL010375500Medicaid
FLHR614ZMedicare PIN