Provider Demographics
NPI:1548469307
Name:MACKENZIE, MICHELE M (CRNA)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:M
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:M
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1410 HARDSCRABBLE BLVD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2704
Mailing Address - Country:US
Mailing Address - Phone:814-838-3793
Mailing Address - Fax:
Practice Address - Street 1:5515 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2603
Practice Address - Country:US
Practice Address - Phone:814-864-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV70449367500000X
PARN331682L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered