Healthcare Provider Details

I. General information

NPI: 1790419174
Provider Name (Legal Business Name): MACKENZIE FAITH THOMPSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACKENZIE LUBBEHUSEN

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W 2ND ST
BLOOMINGTON IN
47403-2217
US

IV. Provider business mailing address

111 NEW HAMPSHIRE AVE STE 2
PORTSMOUTH NH
03801-2864
US

V. Phone/Fax

Practice location:
  • Phone: 812-200-2458
  • Fax: 930-200-8590
Mailing address:
  • Phone: 330-947-6021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004876A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: