Provider Demographics
NPI:1740970383
Name:MCCALISTER, KENZI
Entity type:Individual
Prefix:
First Name:KENZI
Middle Name:
Last Name:MCCALISTER
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 1:44452 N EL MACERO DR
Mailing Address - Street 2:
Mailing Address - City:EL MACERO
Mailing Address - State:CA
Mailing Address - Zip Code:95618-1063
Mailing Address - Country:US
Mailing Address - Phone:530-816-1462
Mailing Address - Fax:
Practice Address - Street 1:44452 N EL MACERO DR
Practice Address - Street 2:
Practice Address - City:EL MACERO
Practice Address - State:CA
Practice Address - Zip Code:95618-1063
Practice Address - Country:US
Practice Address - Phone:530-816-1462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025178363L00000X
CA95241918163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse