Provider Demographics
NPI:1023525532
Name:SULLIVAN, MACKENZIE D (CRNA)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:D
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:D
Other - Last Name:IRVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1527
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78841-1527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 N BEDELL AVE
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4112
Practice Address - Country:US
Practice Address - Phone:830-778-3781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-05
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136337367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX380723201Medicaid