Healthcare Provider Details

I. General information

NPI: 1730027087
Provider Name (Legal Business Name): MACKENZIE LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16635 CENTERFIELD DR STE 204
EAGLE RIVER AK
99577-7746
US

IV. Provider business mailing address

1035 W GRANVILLE ST
PALMER AK
99645-7120
US

V. Phone/Fax

Practice location:
  • Phone: 907-201-0242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number257952
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: