Provider Demographics
NPI:1568080406
Name:ANDERSON, MACKENZIE
Entity Type:Individual
Prefix:MISS
First Name:MACKENZIE
Middle Name:
Last Name:ANDERSON
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 1:100 WALDEN HEIGHTS DR APT 802
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7871
Mailing Address - Country:US
Mailing Address - Phone:478-696-6135
Mailing Address - Fax:
Practice Address - Street 1:100 WALDEN HEIGHTS DR APT 802
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-7871
Practice Address - Country:US
Practice Address - Phone:478-696-6135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program