MEDICARE: MACKENZIE NICOLE KIESLICH PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2020034312	MO

General Provider Information

NPI Number	:	1952045841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE NICOLE KIESLICH PTA

Provider Business Mailing Address
First Line	:	9504 N CHARLOTTE CT
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64155-3124
Country	:	US
Telephone Number	:	816-694-9901
Fax Number	:

Provider Business Practice Location Address
First Line	:	8250 N CHURCH RD STE B
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64158-1103
Country	:	US
Telephone Number	:	816-792-0524
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2022
Last Update Date	:	04/26/2022

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