Provider Demographics
NPI:1225026032
Name:MACKIE, DEANNA (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:
Last Name:MACKIE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 S LAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5243
Mailing Address - Country:US
Mailing Address - Phone:622-234-1731
Mailing Address - Fax:662-236-2392
Practice Address - Street 1:2610 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5243
Practice Address - Country:US
Practice Address - Phone:622-234-1731
Practice Address - Fax:662-236-2392
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR658723363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123497Medicaid
MSQ30236Medicare UPIN
MS500001671Medicare ID - Type Unspecified
MS00123497Medicaid