Healthcare Provider Details

I. General information

NPI: 1548011802
Provider Name (Legal Business Name): MACKENZIE KATHERINE BRISTOL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 E BOULEVARD
KOKOMO IN
46902-2401
US

IV. Provider business mailing address

PO BOX 416501
BOSTON MA
02241-6501
US

V. Phone/Fax

Practice location:
  • Phone: 765-416-8480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: