Provider Demographics
NPI:1851869291
Name:WALKER, MACKENZIE B
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:B
Last Name:WALKER
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 1:12 CREST RD
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-9701
Mailing Address - Country:US
Mailing Address - Phone:802-524-4554
Mailing Address - Fax:
Practice Address - Street 1:12 CREST RD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-9701
Practice Address - Country:US
Practice Address - Phone:802-524-4554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-03
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023473363A00000X
390200000X
VT055.0031576363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program