Provider Demographics
NPI:1992549984
Name:BREAULT, MCKENZIE GAIL
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:GAIL
Last Name:BREAULT
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 1:1528 LEILA LN
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-1083
Mailing Address - Country:US
Mailing Address - Phone:715-220-7117
Mailing Address - Fax:
Practice Address - Street 1:600 S 43RD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4418
Practice Address - Country:US
Practice Address - Phone:715-220-7117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant