Provider Demographics
NPI:1548844947
Name:MCKENZIE, OTENSIA MICHELE (DO)
Entity type:Individual
Prefix:MS
First Name:OTENSIA
Middle Name:MICHELE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 S BRYN MAWR AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3129
Mailing Address - Country:US
Mailing Address - Phone:610-325-1390
Mailing Address - Fax:
Practice Address - Street 1:135 S BRYN MAWR AVE STE 200
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3129
Practice Address - Country:US
Practice Address - Phone:610-325-1390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOT023077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program