Provider Demographics
NPI:1649749714
Name:BLAIR, MACKENZIE ANNE (RD)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANNE
Last Name:BLAIR
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 VETERANS MEMORIAL PKWY
Mailing Address - Street 2:STE 8C
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-5300
Mailing Address - Country:US
Mailing Address - Phone:434-203-3004
Mailing Address - Fax:
Practice Address - Street 1:450 VETERANS MEMORIAL PKWY STE 8C
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-5300
Practice Address - Country:US
Practice Address - Phone:401-396-9331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN00993133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86099726OtherCOMMISSION ON DIETETIC REGISTRATION