Provider Demographics
NPI:1144589086
Name:MACKENZIE, WAYNE SR (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:
Last Name:MACKENZIE
Suffix:SR
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 N LITCHFIELD RD STE 105
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1256
Mailing Address - Country:US
Mailing Address - Phone:623-224-1162
Mailing Address - Fax:888-346-3899
Practice Address - Street 1:319 N LITCHFIELD RD STE 105
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1256
Practice Address - Country:US
Practice Address - Phone:623-224-1162
Practice Address - Fax:888-346-3899
Is Sole Proprietor?:No
Enumeration Date:2012-05-13
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX707607363LP0808X
OR201250163NP363LP0808X
AZAP4913363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ804045OtherAHCCCS
AZQXIPQ0000098776Medicaid