Basic Information
| Provider Information | |||||||||
| NPI: | 1235596370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | MCKENZIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MNT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 S 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | MARSHALLTOWN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501582924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6417545145 | ||||||||
| FaxNumber: | 6418446208 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 S 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | MARSHALLTOWN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501582924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6417545145 | ||||||||
| FaxNumber: | 6418446208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2016 | ||||||||
| LastUpdateDate: | 01/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 080420 | IA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.