Provider Demographics
NPI:1174149744
Name:MCKENZIE, DELLSHONE TYRECE
Entity type:Individual
Prefix:
First Name:DELLSHONE
Middle Name:TYRECE
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 1:24 W RAILROAD AVE STE 168
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-1735
Mailing Address - Country:US
Mailing Address - Phone:862-668-0981
Mailing Address - Fax:
Practice Address - Street 1:24 W RAILROAD AVE STE 168
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-1735
Practice Address - Country:US
Practice Address - Phone:862-668-0981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJM16221608308882171W00000X
171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor