Provider Demographics
NPI:1700692399
Name:MORTENSEN, MEKENNA MARIE
Entity type:Individual
Prefix:
First Name:MEKENNA
Middle Name:MARIE
Last Name:MORTENSEN
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 1:3214 BARKERS FOREST LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-5545
Mailing Address - Country:US
Mailing Address - Phone:832-293-7377
Mailing Address - Fax:
Practice Address - Street 1:707 S 8TH ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1811
Practice Address - Country:US
Practice Address - Phone:719-633-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0024948183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist