Provider Demographics
NPI:1770578676
Name:MCKENZIE, NISHA KIMBERLY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NISHA
Middle Name:KIMBERLY
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:630 KENMOOR AVE SE STE 103
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8626
Mailing Address - Country:US
Mailing Address - Phone:616-600-4950
Mailing Address - Fax:855-817-3028
Practice Address - Street 1:630 KENMOOR AVE SE STE 103
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8626
Practice Address - Country:US
Practice Address - Phone:616-600-4950
Practice Address - Fax:855-817-3028
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003946363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N67230Medicare ID - Type Unspecified