Provider Demographics
NPI:1104588326
Name:FREDERICK, MCKENZI (RN)
Entity type:Individual
Prefix:
First Name:MCKENZI
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MCKENZI
Other - Middle Name:
Other - Last Name:BLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4241 HIGHWAY 14 W
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-1037
Mailing Address - Country:US
Mailing Address - Phone:618-724-1684
Mailing Address - Fax:
Practice Address - Street 1:165 KINNAMAN DR
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-4204
Practice Address - Country:US
Practice Address - Phone:618-662-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041501632163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse