Healthcare Provider Details

I. General information

NPI: 1205792322
Provider Name (Legal Business Name): MACKENZIE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2026
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N ROYAL ST
DERIDDER LA
70634-3851
US

IV. Provider business mailing address

PO BOX 642
DRY CREEK LA
70637-0642
US

V. Phone/Fax

Practice location:
  • Phone: 337-202-8803
  • Fax: 337-222-4013
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: