Provider Demographics
NPI:1902611312
Name:MYERS, MACKENZIE GRACE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:GRACE
Last Name:MYERS
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 1:711 CARMELL CT
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-7806
Mailing Address - Country:US
Mailing Address - Phone:715-222-4573
Mailing Address - Fax:
Practice Address - Street 1:64 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3409
Practice Address - Country:US
Practice Address - Phone:715-222-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program