Provider Demographics
NPI:1881366227
Name:KUNNECKE, MCKENZIE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:KUNNECKE
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 1:633 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:CALVERT CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42029-8315
Mailing Address - Country:US
Mailing Address - Phone:270-703-4462
Mailing Address - Fax:
Practice Address - Street 1:214 MAIN ST
Practice Address - Street 2:
Practice Address - City:CADIZ
Practice Address - State:KY
Practice Address - Zip Code:42211-9153
Practice Address - Country:US
Practice Address - Phone:270-522-0898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016123363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily