Provider Demographics
NPI:1326859810
Name:EWALD, MCKENZIE LEIGH (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:LEIGH
Last Name:EWALD
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1301 WOODS EDGE CT
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34715-5603
Mailing Address - Country:US
Mailing Address - Phone:859-609-1049
Mailing Address - Fax:
Practice Address - Street 1:2910 MAGUIRE RD STE 2002
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4742
Practice Address - Country:US
Practice Address - Phone:239-690-6906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-15
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11037180363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health