Provider Demographics
NPI:1629629761
Name:GIBBONS, MACKENZIE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16532 US HIGHWAY 64
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38068-6185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16532 US HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-6185
Practice Address - Country:US
Practice Address - Phone:901-813-8138
Practice Address - Fax:901-813-8793
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26479363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty