Provider Demographics
NPI:1407330814
Name:MACKENZIE, DEANNA
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:MACKENZIE
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 1:3596 K RD
Mailing Address - Street 2:
Mailing Address - City:BARK RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49807-9731
Mailing Address - Country:US
Mailing Address - Phone:906-367-1471
Mailing Address - Fax:
Practice Address - Street 1:2415 5TH AVE S
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1201
Practice Address - Country:US
Practice Address - Phone:906-786-6907
Practice Address - Fax:906-786-8300
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant