Provider Demographics
NPI:1770199739
Name:RENKERT, MACKENZIE LAUREN
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LAUREN
Last Name:RENKERT
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 1:203A UMATILLA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-5039
Mailing Address - Country:US
Mailing Address - Phone:425-770-0453
Mailing Address - Fax:
Practice Address - Street 1:532 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3185
Practice Address - Country:US
Practice Address - Phone:360-683-7911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60877318225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist