Provider Demographics
NPI:1346793445
Name:LAKE, MCKENZIE MACK (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MCKENZIE
Middle Name:MACK
Last Name:LAKE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 DELFINIO DR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-2947
Mailing Address - Country:US
Mailing Address - Phone:505-550-9863
Mailing Address - Fax:
Practice Address - Street 1:3001 BROADMOOR BLVD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-2100
Practice Address - Country:US
Practice Address - Phone:505-550-9863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02964363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily