Healthcare Provider Details

I. General information

NPI: 1932740214
Provider Name (Legal Business Name): MACKENZIE DILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 01/22/2024
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W TURNER RD STE 450
LODI CA
95242
US

IV. Provider business mailing address

2401 W TURNER RD STE 450
LODI CA
95242-2191
US

V. Phone/Fax

Practice location:
  • Phone: 209-370-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM05720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: