Provider Demographics
NPI:1922446889
Name:DOUGLASS, MACKENZIE E (MSN, CNM)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:E
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:MSN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1505 SOQUEL DR STE 1
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1716
Practice Address - Country:US
Practice Address - Phone:831-465-5440
Practice Address - Fax:831-462-2017
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNM.019342367A00000X
IL209.010345367A00000X
CA95212458367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife