Provider Demographics
NPI:1174292072
Name:KELLAR, MACKENZIE
Entity Type:Individual
Prefix:MS
First Name:MACKENZIE
Middle Name:
Last Name:KELLAR
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 1:172 MARLBOROUGH ST APT BF
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-1842
Mailing Address - Country:US
Mailing Address - Phone:517-630-1093
Mailing Address - Fax:
Practice Address - Street 1:360 HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5000
Practice Address - Country:US
Practice Address - Phone:617-373-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program