Provider Demographics
NPI:1750312633
Name:MCKENZIE, KELLY SUE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11321 SNOW LINE DR NW
Mailing Address - Street 2:
Mailing Address - City:FROSTBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21532
Mailing Address - Country:US
Mailing Address - Phone:301-689-0436
Mailing Address - Fax:
Practice Address - Street 1:12500 WILLOWBROOK RD
Practice Address - Street 2:WESTERN MD REGIONAL HEALTH SYSTEM
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6393
Practice Address - Country:US
Practice Address - Phone:240-964-3306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV51177367500000X
MD049080367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD854129900Medicaid
5516216VMedicare ID - Type Unspecified