1750312633 NPI number — MRS. KELLY SUE MCKENZIE CRNA

Table of content: MRS. KELLY SUE MCKENZIE CRNA (NPI 1750312633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750312633 NPI number — MRS. KELLY SUE MCKENZIE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKENZIE
Provider First Name:
KELLY
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750312633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11321 SNOW LINE DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FROSTBURG
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-689-0436
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12500 WILLOWBROOK RD
Provider Second Line Business Practice Location Address:
WESTERN MD REGIONAL HEALTH SYSTEM
Provider Business Practice Location Address City Name:
CUMBERLAND
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21502-6393
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-964-3306
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  51177 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 049080 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 854129900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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