Provider Demographics
NPI:1063906741
Name:HERNDON, MCKENZIE NICOLE (BSW)
Entity type:Individual
Prefix:MRS
First Name:MCKENZIE
Middle Name:NICOLE
Last Name:HERNDON
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 OLD IVY TRCE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-5718
Mailing Address - Country:US
Mailing Address - Phone:229-561-3920
Mailing Address - Fax:
Practice Address - Street 1:4141 OLD IVY TRCE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-5718
Practice Address - Country:US
Practice Address - Phone:229-561-3920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor