Provider Demographics
NPI:1891570453
Name:MACKENZIE, RYAN MICHAEL
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3647 FOREST SPRING DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48359-1590
Mailing Address - Country:US
Mailing Address - Phone:248-860-3190
Mailing Address - Fax:
Practice Address - Street 1:3647 FOREST SPRING DR
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-1590
Practice Address - Country:US
Practice Address - Phone:248-860-3190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704268806363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care