Provider Demographics
NPI:1912959701
Name:MCKENZIE, HEATHER MARIE (DPM)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3907 BRIDGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1133
Mailing Address - Country:US
Mailing Address - Phone:757-977-1026
Mailing Address - Fax:757-977-1027
Practice Address - Street 1:3907 BRIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-1133
Practice Address - Country:US
Practice Address - Phone:757-977-1026
Practice Address - Fax:757-799-1027
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300937213ES0103X
VA1912959701213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010181968Medicaid
VAV05587Medicare UPIN
VA010181968Medicaid
VA00W434M01Medicare PIN