Provider Demographics
NPI:1538927645
Name:DAMM, MACKENZIE (RD)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:DAMM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:CLIFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5327 RALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3423
Mailing Address - Country:US
Mailing Address - Phone:317-366-4667
Mailing Address - Fax:
Practice Address - Street 1:5327 RALSTON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3423
Practice Address - Country:US
Practice Address - Phone:317-366-4667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86118804133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered