Provider Demographics
NPI:1164251559
Name:SISKAVICH, MACKENZIE SHIRLEY
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:SHIRLEY
Last Name:SISKAVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 STATE ROUTE 22B APT A
Mailing Address - Street 2:
Mailing Address - City:MORRISONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12962-3652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1939 STATE ROUTE 22B APT A
Practice Address - Street 2:
Practice Address - City:MORRISONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12962-3652
Practice Address - Country:US
Practice Address - Phone:518-569-6578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344852-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty