Healthcare Provider Details

I. General information

NPI: 1538932959
Provider Name (Legal Business Name): MACKENZIE PAYTON JO SPEAR APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5872 SCOTTSVILLE RD
BOWLING GREEN KY
42104-7853
US

IV. Provider business mailing address

813 NUTWOOD ST
BOWLING GREEN KY
42103-4927
US

V. Phone/Fax

Practice location:
  • Phone: 270-746-9300
  • Fax:
Mailing address:
  • Phone: 270-535-1342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number4010378
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: