Provider Demographics
NPI:1770385742
Name:MACKENZIE, LAURIE JOHN (FNP)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:JOHN
Last Name:MACKENZIE
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 CLAREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-3506
Mailing Address - Country:US
Mailing Address - Phone:707-372-0577
Mailing Address - Fax:
Practice Address - Street 1:208 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-3506
Practice Address - Country:US
Practice Address - Phone:707-372-0577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95034105363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty