Provider Demographics
NPI:1114456340
Name:LEEKE, MACKENZIE ROSE (LM)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ROSE
Last Name:LEEKE
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-3014
Mailing Address - Country:US
Mailing Address - Phone:530-277-2043
Mailing Address - Fax:
Practice Address - Street 1:6940 DESTINY DR
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2987
Practice Address - Country:US
Practice Address - Phone:916-223-7731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM500176B00000X
CA500175M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175M00000XOther Service ProvidersMidwife, Lay
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114456340OtherNPPES