Healthcare Provider Details

I. General information

NPI: 1861023921
Provider Name (Legal Business Name): COURTNEY ANN MACKINNON WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4951 S WHITE MOUNTAIN RD BLDG A
SHOW LOW AZ
85901-7827
US

IV. Provider business mailing address

1190 E PINE OAKS DR
SHOW LOW AZ
85901-7356
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-6700
  • Fax: 928-537-4439
Mailing address:
  • Phone: 928-242-4347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number237275
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: