Healthcare Provider Details

I. General information

NPI: 1346177961
Provider Name (Legal Business Name): MACKENZIE PRUSACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 BROADWAY UNIT 545
SAN DIEGO CA
92101-5802
US

IV. Provider business mailing address

1509 BROADWAY UNIT 545
SAN DIEGO CA
92101-5802
US

V. Phone/Fax

Practice location:
  • Phone: 925-864-6701
  • Fax:
Mailing address:
  • Phone: 925-864-6701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: