Healthcare Provider Details

I. General information

NPI: 1073191391
Provider Name (Legal Business Name): MACKENZIE DIANNE HUDSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 SW HEALTH PKWY STE 205
NAPLES FL
34109-0473
US

IV. Provider business mailing address

10123 SWEETGRASS CIR UNIT 307
NAPLES FL
34104-0898
US

V. Phone/Fax

Practice location:
  • Phone: 239-449-7979
  • Fax:
Mailing address:
  • Phone: 339-237-7535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: