Basic Information
| Provider Information | |||||||||
| NPI: | 1851843114 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKENZIE | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | SEAN | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044877726 | ||||||||
| FaxNumber: | 3044315263 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044877726 | ||||||||
| FaxNumber: | 3044315263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2016 | ||||||||
| LastUpdateDate: | 03/24/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1851843114 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | APRN60413-FNP-BC | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.