Provider Demographics
NPI:1437764735
Name:WILSON, MACKENZIE CARA
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:CARA
Last Name:WILSON
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 1:1245 COUNTY ROUTE 25
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-6023
Mailing Address - Country:US
Mailing Address - Phone:518-483-3261
Mailing Address - Fax:
Practice Address - Street 1:31 6TH ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1246
Practice Address - Country:US
Practice Address - Phone:518-483-3261
Practice Address - Fax:518-483-3383
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist