Provider Demographics
NPI:1215692819
Name:MCKENZIE, BREANNA
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
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 1:1076 BROOKSIDE AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5055
Mailing Address - Country:US
Mailing Address - Phone:909-233-0458
Mailing Address - Fax:
Practice Address - Street 1:1076 BROOKSIDE AVE APT 202
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5055
Practice Address - Country:US
Practice Address - Phone:909-233-0458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA716885164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse