Provider Demographics
NPI:1063292233
Name:MCKENZIE, RENATTO DIEAGO (RN)
Entity type:Individual
Prefix:MR
First Name:RENATTO
Middle Name:DIEAGO
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BLUEBERRY LN
Mailing Address - Street 2:
Mailing Address - City:LYNDEBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03082-5617
Mailing Address - Country:US
Mailing Address - Phone:603-438-3623
Mailing Address - Fax:
Practice Address - Street 1:718 SMYTH RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-7007
Practice Address - Country:US
Practice Address - Phone:603-624-4366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2297979163WG0000X
NH069566-21163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice