Provider Demographics
NPI:1063977312
Name:MCKENZIE, REBECCA GAIL
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:GAIL
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6382 N BRENDA LN
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-4039
Mailing Address - Country:US
Mailing Address - Phone:909-965-2880
Mailing Address - Fax:
Practice Address - Street 1:18300 CA-18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-242-2311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86075778133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86075778OtherACADEMY OF NUTRITION AND DIETETICS