Provider Demographics
NPI:1669213963
Name:SHIELDS, MACKENZIE GRACE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:GRACE
Last Name:SHIELDS
Suffix:
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 1:1089 OVERPASS RD
Mailing Address - Street 2:
Mailing Address - City:COTTONDALE
Mailing Address - State:FL
Mailing Address - Zip Code:32431-8943
Mailing Address - Country:US
Mailing Address - Phone:850-718-7624
Mailing Address - Fax:
Practice Address - Street 1:4419 TRAM RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-2559
Practice Address - Country:US
Practice Address - Phone:850-747-5401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTAT33491225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant