Provider Demographics
NPI:1023725140
Name:HULL, MACKENZIE EVELINA I
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:EVELINA
Last Name:HULL
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15710 NE 93RD ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-1508
Mailing Address - Country:US
Mailing Address - Phone:360-953-2883
Mailing Address - Fax:
Practice Address - Street 1:1319 NE 134TH ST STE 103
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2718
Practice Address - Country:US
Practice Address - Phone:360-574-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61335967225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty