Provider Demographics
NPI:1780086231
Name:MACKENZIE, LOIS (RN)
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 619
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:CO
Mailing Address - Zip Code:81433-0619
Mailing Address - Country:US
Mailing Address - Phone:970-387-0242
Mailing Address - Fax:970-387-5036
Practice Address - Street 1:1315 SNOWDEN
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:CO
Practice Address - Zip Code:81433
Practice Address - Country:US
Practice Address - Phone:970-387-0242
Practice Address - Fax:970-387-5036
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0108381163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO83723561Medicaid