Provider Demographics
NPI:1043441066
Name:JOHNSON, MACKENZIE RENAE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RENAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 THISTLE RD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-7790
Mailing Address - Country:US
Mailing Address - Phone:928-856-1362
Mailing Address - Fax:
Practice Address - Street 1:1809 THISTLE RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-7790
Practice Address - Country:US
Practice Address - Phone:928-856-1362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-07
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ120200246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist