Provider Demographics
NPI:1982483640
Name:LANNON, MAKENZIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:
Last Name:LANNON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 PUTTING GREEN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1104
Mailing Address - Country:US
Mailing Address - Phone:203-814-8105
Mailing Address - Fax:
Practice Address - Street 1:310 N SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1810
Practice Address - Country:US
Practice Address - Phone:310-423-9331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95025664363LF0000X
NYF-351165363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily