Provider Demographics
NPI:1548606544
Name:MACKENZIE, SABRINA GRACE
Entity Type:Individual
Prefix:
First Name:SABRINA
Middle Name:GRACE
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 1:2820 ROUTE 104
Mailing Address - Street 2:
Mailing Address - City:EAST QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11942-3711
Mailing Address - Country:US
Mailing Address - Phone:631-579-5694
Mailing Address - Fax:
Practice Address - Street 1:2820 ROUTE 104
Practice Address - Street 2:
Practice Address - City:EAST QUOGUE
Practice Address - State:NY
Practice Address - Zip Code:11942-3711
Practice Address - Country:US
Practice Address - Phone:631-579-5694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312425164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYSGM1457Medicaid