Provider Demographics
NPI:1790483782
Name:MCNAMARA, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:MCNAMARA
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 1:1222 ROANOKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-5204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1222 ROANOKE BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-5204
Practice Address - Country:US
Practice Address - Phone:540-355-9052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001270228163W00000X
VA0024189369367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse