Provider Demographics
NPI:1225654866
Name:RUNNE, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:RUNNE
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 1:1070 RED HAWK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ARIEL
Mailing Address - State:PA
Mailing Address - Zip Code:18436-8110
Mailing Address - Country:US
Mailing Address - Phone:570-872-4719
Mailing Address - Fax:
Practice Address - Street 1:1070 RED HAWK DR
Practice Address - Street 2:
Practice Address - City:LAKE ARIEL
Practice Address - State:PA
Practice Address - Zip Code:18436-8110
Practice Address - Country:US
Practice Address - Phone:570-872-4719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program