Provider Demographics
NPI:1790419174
Name:LUBBEHUSEN, MACKENZIE FAITH
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:FAITH
Last Name:LUBBEHUSEN
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 1:412 S CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47542-9692
Mailing Address - Country:US
Mailing Address - Phone:812-827-9519
Mailing Address - Fax:
Practice Address - Street 1:412 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-9692
Practice Address - Country:US
Practice Address - Phone:812-827-9519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant