Provider Demographics
NPI:1699371625
Name:CEBULLA, MEGAN MACKENZIE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MACKENZIE
Last Name:CEBULLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1413
Mailing Address - Country:US
Mailing Address - Phone:763-684-4646
Mailing Address - Fax:
Practice Address - Street 1:109 2ND ST S
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1413
Practice Address - Country:US
Practice Address - Phone:763-684-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-06
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6774111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor