Provider Demographics
NPI:1548372386
Name:MACKENZIE, MONICA A (NPC)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:A
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 CAMPUS RIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640
Mailing Address - Country:US
Mailing Address - Phone:989-488-5450
Mailing Address - Fax:989-488-5455
Practice Address - Street 1:4201 CAMPUS RIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640
Practice Address - Country:US
Practice Address - Phone:989-488-5450
Practice Address - Fax:989-488-5455
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704215621363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1029791OtherMCLAREN HEALTH PLAN
MI0Z90078OtherBCBS
MI0Z90077OtherBCBS
Q55873Medicare UPIN