Healthcare Provider Details

I. General information

NPI: 1861253908
Provider Name (Legal Business Name): MACKENZIE POTTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11621 KEW GARDENS AVE STE 101A
PALM BEACH GARDENS FL
33410-2853
US

IV. Provider business mailing address

609 2ND ST APT 200
WEST PALM BEACH FL
33401-4506
US

V. Phone/Fax

Practice location:
  • Phone: 561-253-3980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9121965
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: