Provider Demographics
NPI:1003531666
Name:CLARK, MACKENZIE MARGARET (ND)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MARGARET
Last Name:CLARK
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 6TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-2920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:470 6TH ST STE C
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034
Practice Address - Country:US
Practice Address - Phone:503-505-9806
Practice Address - Fax:503-505-9807
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4477175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath