Provider Demographics
NPI:1922425156
Name:VANGORDER, MAKENZIE LIN (BA)
Entity Type:Individual
Prefix:MS
First Name:MAKENZIE
Middle Name:LIN
Last Name:VANGORDER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MS
Other - First Name:MAKENZIE
Other - Middle Name:LIN
Other - Last Name:DERBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3407 SHAMROCK CT
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3407 SHAMROCK CT
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5337
Practice Address - Country:US
Practice Address - Phone:228-497-0690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid