Provider Demographics
NPI:1881264059
Name:IVORY, MACKENZIE (NBC-HIS)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:IVORY
Suffix:
Gender:F
Credentials:NBC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 N 400 E STE 101
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-7578
Mailing Address - Country:US
Mailing Address - Phone:801-495-4800
Mailing Address - Fax:
Practice Address - Street 1:1515 N 400 E STE 101
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7578
Practice Address - Country:US
Practice Address - Phone:801-495-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11060893-4602237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist