Provider Demographics
NPI:1013726561
Name:COSTON, MACKENZIE ELIZABETH (CGC)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ELIZABETH
Last Name:COSTON
Suffix:
Gender:F
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 S BOUNDARY ST APT 311
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-8507
Mailing Address - Country:US
Mailing Address - Phone:360-393-7727
Mailing Address - Fax:
Practice Address - Street 1:501 N GRAHAM ST STE 330B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-2009
Practice Address - Country:US
Practice Address - Phone:360-393-7727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS