Provider Demographics
NPI:1679072250
Name:EVANS, MCKENZIE NICOLE (LMP)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:NICOLE
Last Name:EVANS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 4TH AVE S STE C
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-3515
Mailing Address - Country:US
Mailing Address - Phone:425-778-2838
Mailing Address - Fax:425-640-7423
Practice Address - Street 1:115 4TH AVE S STE C
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3515
Practice Address - Country:US
Practice Address - Phone:425-778-2838
Practice Address - Fax:425-640-7423
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60827443225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist