Provider Demographics
NPI:1699768101
Name:MCKENZIE, STACEY W (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:W
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70403
Mailing Address - Street 2:365 STOUT DRIVE
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4515
Mailing Address - Fax:423-439-5780
Practice Address - Street 1:2151 CENTURY LN
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4469
Practice Address - Country:US
Practice Address - Phone:423-926-2500
Practice Address - Fax:423-926-5999
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18756207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ010241Medicaid
TN1031I15209Medicare PIN
KY0234509Medicare ID - Type Unspecified
KYE50991Medicare UPIN
234509Medicare PIN