Provider Demographics
NPI:1629682596
Name:BOWERS, MACKENZIE MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MARIE
Last Name:BOWERS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:MARIE
Other - Last Name:O'MALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 MEMORIAL DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1589
Mailing Address - Country:US
Mailing Address - Phone:217-876-2756
Mailing Address - Fax:217-876-3585
Practice Address - Street 1:2 MEMORIAL DR STE 101
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1589
Practice Address - Country:US
Practice Address - Phone:217-876-2756
Practice Address - Fax:217-876-3585
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021422363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily