Healthcare Provider Details

I. General information

NPI: 1932026523
Provider Name (Legal Business Name): MACKENZIE PORTER WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 W IRONWOOD DR STE 306
COEUR D ALENE ID
83814-2668
US

IV. Provider business mailing address

980 W IRONWOOD DR STE 306
COEUR D ALENE ID
83814-2668
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-4970
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number2120788
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: