Provider Demographics
NPI:1417396524
Name:CLARK, MACKENZIE ROCHON (APNP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ROCHON
Last Name:CLARK
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:ROCHON
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:5395 E CHERYL PKWY
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-5395
Mailing Address - Country:US
Mailing Address - Phone:608-276-4660
Mailing Address - Fax:
Practice Address - Street 1:5395 E CHERYL PKWY
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-5395
Practice Address - Country:US
Practice Address - Phone:608-276-4660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI155942-30163W00000X
WI4852-33363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400102963Medicare PIN
WIK400102962Medicare PIN