Provider Demographics
NPI:1891205373
Name:GRILLO, MACKENZIE LURENE MASHBURN (NP)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LURENE MASHBURN
Last Name:GRILLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 HIGH NOONTIDE WAY NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6967
Mailing Address - Country:US
Mailing Address - Phone:678-640-5023
Mailing Address - Fax:
Practice Address - Street 1:8954 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2272
Practice Address - Country:US
Practice Address - Phone:678-640-5023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191815363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care