Provider Demographics
NPI:1295415834
Name:REAY, MACKENZIE ELIZABETH (NP)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ELIZABETH
Last Name:REAY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FATHOM DR
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1417
Mailing Address - Country:US
Mailing Address - Phone:949-228-0231
Mailing Address - Fax:
Practice Address - Street 1:6 FATHOM DR
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-1417
Practice Address - Country:US
Practice Address - Phone:949-228-0231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2028648363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care