Provider Demographics
NPI:1548923527
Name:PRENTICE, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:PRENTICE
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:S73W17268 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-9353
Mailing Address - Country:US
Mailing Address - Phone:507-398-6144
Mailing Address - Fax:
Practice Address - Street 1:S73W17268 LAKE DR
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-9353
Practice Address - Country:US
Practice Address - Phone:507-398-6144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11460363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11460OtherWISCONSIN APNP LICENSE NUMBER