Provider Demographics
NPI:1356955181
Name:STUTZMAN, MACKENZIE NICOLE (CNP)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:NICOLE
Last Name:STUTZMAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MALL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8000
Mailing Address - Fax:
Practice Address - Street 1:10506 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4487
Practice Address - Country:US
Practice Address - Phone:513-865-2227
Practice Address - Fax:513-865-5552
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0026900363LA2100X
MARN2357906363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2565399Medicaid