Provider Demographics
NPI:1588074298
Name:MCKENZIE, ELISHA
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5966 RIDGE LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32967-5092
Mailing Address - Country:US
Mailing Address - Phone:772-646-1112
Mailing Address - Fax:
Practice Address - Street 1:5966 RIDGE LAKE CIR
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32967-5092
Practice Address - Country:US
Practice Address - Phone:772-646-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker