Provider Demographics
NPI:1972542504
Name:MACKENZIE, DIANA CHARLENE (LPN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:CHARLENE
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 LANSING STATION RD
Mailing Address - Street 2:A3
Mailing Address - City:LANSING
Mailing Address - State:NY
Mailing Address - Zip Code:14882-8831
Mailing Address - Country:US
Mailing Address - Phone:607-227-6240
Mailing Address - Fax:
Practice Address - Street 1:620 LANSING STATION RD
Practice Address - Street 2:A3
Practice Address - City:LANSING
Practice Address - State:NY
Practice Address - Zip Code:14882-8831
Practice Address - Country:US
Practice Address - Phone:607-227-6240
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246199-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02714845Medicaid
NYVD3Medicaid