Healthcare Provider Details

I. General information

NPI: 1477208882
Provider Name (Legal Business Name): MACKENZIE KUCKS APRN-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E TWIGGS ST STE 103
TAMPA FL
33602-3925
US

IV. Provider business mailing address

625 E TWIGGS ST STE 103
TAMPA FL
33602-3925
US

V. Phone/Fax

Practice location:
  • Phone: 813-228-7696
  • Fax: 813-228-0677
Mailing address:
  • Phone: 813-228-7696
  • Fax: 813-228-0677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number11018125
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: