Provider Demographics
NPI:1720691652
Name:MACKENZIE, HANNAH
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:
Other - Last Name:REGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:403 SUMMIT BLVD UNIT 204
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021-8253
Mailing Address - Country:US
Mailing Address - Phone:720-401-2139
Mailing Address - Fax:
Practice Address - Street 1:403 SUMMIT BLVD UNIT 204
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021-8253
Practice Address - Country:US
Practice Address - Phone:720-401-2139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-29
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COPA.0007580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program