Provider Demographics
NPI:1225892409
Name:MARTIN, MACKENZIE RACHELLE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RACHELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:RACHELLE
Other - Last Name:IBISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:216 S LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4547
Mailing Address - Country:US
Mailing Address - Phone:918-892-2572
Mailing Address - Fax:
Practice Address - Street 1:216 S LINDEN ST
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4547
Practice Address - Country:US
Practice Address - Phone:918-892-2572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator