Provider Demographics
NPI:1932856184
Name:MCKENZIE, NICHOLAS LANCE
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:LANCE
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14608 JOSAIR DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-5343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:924 E 57TH ST # 104
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1455
Practice Address - Country:US
Practice Address - Phone:773-702-1937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program