Provider Demographics
NPI:1376217141
Name:BURRELL, MACKINLEY SPENCER (CP)
Entity Type:Individual
Prefix:
First Name:MACKINLEY
Middle Name:SPENCER
Last Name:BURRELL
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42212 N 41ST DR STE 105
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3815
Mailing Address - Country:US
Mailing Address - Phone:623-352-4520
Mailing Address - Fax:833-680-2415
Practice Address - Street 1:42212 N 41ST DR STE 105
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3815
Practice Address - Country:US
Practice Address - Phone:623-352-4520
Practice Address - Fax:833-680-2415
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACP004467224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist