Provider Demographics
NPI:1528555703
Name:FOSTER, MACKENZIE (CRNP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:FOSTER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W LANCASTER AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1798
Mailing Address - Country:US
Mailing Address - Phone:610-644-8069
Mailing Address - Fax:
Practice Address - Street 1:250 W LANCASTER AVE STE 120
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1798
Practice Address - Country:US
Practice Address - Phone:610-644-8069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018772363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232086521OtherTAX ID