Provider Demographics
NPI:1043656242
Name:MACKINNON, MONICA DIANE
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:DIANE
Last Name:MACKINNON
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 1:800 SCENIC DR BLDG 4
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:209-525-6160
Mailing Address - Fax:
Practice Address - Street 1:800 SCENIC DR BLDG 4
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-525-6160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician