Provider Demographics
NPI:1710631544
Name:JOHNSON, MACKENZIE (APRN)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11632 CROWNED SPARROW LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1812 HEALTH CARE DR
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-5362
Practice Address - Country:US
Practice Address - Phone:813-731-0944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11018063363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics