Provider Demographics
NPI:1639846306
Name:SILL, MACKENZIE (PTA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:SILL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16194 PIN OAK RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-8102
Mailing Address - Country:US
Mailing Address - Phone:479-422-7537
Mailing Address - Fax:
Practice Address - Street 1:3625 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-0351
Practice Address - Country:US
Practice Address - Phone:479-246-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4701225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant