Healthcare Provider Details

I. General information

NPI: 1891331211
Provider Name (Legal Business Name): MACKENZIE ROSE KILPATRICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACKENZIE ROSE MARTIN PA-C

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

988 SILAS DEANE HWY
WETHERSFIELD CT
06109-4227
US

IV. Provider business mailing address

988 SILAS DEANE HWY
WETHERSFIELD CT
06109-4227
US

V. Phone/Fax

Practice location:
  • Phone: 860-493-1950
  • Fax:
Mailing address:
  • Phone: 860-493-1950
  • Fax: 860-493-1961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4639
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: