Provider Demographics
NPI:1144556564
Name:MACKENZIE, DACIA WILSON (CRNA)
Entity type:Individual
Prefix:
First Name:DACIA
Middle Name:WILSON
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DACY
Other - Middle Name:R
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:3920 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4702
Practice Address - Country:US
Practice Address - Phone:502-259-6710
Practice Address - Fax:502-259-6704
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4087367500000X
KY3015650367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100717610Medicaid
IN300047669Medicaid
SCAN2027Medicaid