Provider Demographics
NPI:1619610805
Name:LAVELY, MACKENZIE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANN
Last Name:LAVELY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 CLAIRTON BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15236-5511
Mailing Address - Country:US
Mailing Address - Phone:412-650-1150
Mailing Address - Fax:
Practice Address - Street 1:810 CLAIRTON BLVD STE 400
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15236-5511
Practice Address - Country:US
Practice Address - Phone:412-650-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
PAMA063613363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical