Provider Demographics
NPI:1033897731
Name:CASEY, MACKENZIE (FNP-BC, RN)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:CASEY
Suffix:
Gender:F
Credentials:FNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 PORTLAND ST UNIT 706
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2042
Mailing Address - Country:US
Mailing Address - Phone:805-400-5303
Mailing Address - Fax:
Practice Address - Street 1:36 1ST AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02129-4557
Practice Address - Country:US
Practice Address - Phone:617-726-2947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2358133163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse