Provider Demographics
NPI:1790501609
Name:FORD, MACKENZIE NOELLE (APRN)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:NOELLE
Last Name:FORD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 W CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4621
Mailing Address - Country:US
Mailing Address - Phone:918-509-4440
Mailing Address - Fax:918-509-4677
Practice Address - Street 1:1103 W CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4621
Practice Address - Country:US
Practice Address - Phone:918-509-4440
Practice Address - Fax:918-509-4677
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK220996363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty