Provider Demographics
NPI:1326749441
Name:SMITH, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:SMITH
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 1:16511 LOWELL AVE APT 8404
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:KS
Mailing Address - Zip Code:66085-7918
Mailing Address - Country:US
Mailing Address - Phone:913-484-3239
Mailing Address - Fax:
Practice Address - Street 1:16511 LOWELL AVE APT 8404
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:KS
Practice Address - Zip Code:66085-7918
Practice Address - Country:US
Practice Address - Phone:913-484-3239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant