Provider Demographics
NPI:1144793167
Name:LANE, MACKENZIE (DPT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:MIKOLAJCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1395 N COURTENAY PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4474
Mailing Address - Country:US
Mailing Address - Phone:321-986-8812
Mailing Address - Fax:321-327-2130
Practice Address - Street 1:1395 N COURTENAY PKWY STE 102
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953
Practice Address - Country:US
Practice Address - Phone:321-986-8812
Practice Address - Fax:321-327-2130
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTT34299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PTT34299OtherPT LICENSE