Provider Demographics
NPI:1992812432
Name:MCKENZIE, LISA LYNN (CRNA)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:LYNN
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:CRNA
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 226
Mailing Address - Street 2:
Mailing Address - City:FLAR TOP
Mailing Address - State:WV
Mailing Address - Zip Code:25841-0226
Mailing Address - Country:US
Mailing Address - Phone:304-787-4703
Mailing Address - Fax:
Practice Address - Street 1:501 MORRIS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-388-6261
Practice Address - Fax:304-388-3604
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV49571163W00000X
WV070062367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00303279Medicaid
WV3810000269Medicaid