Healthcare Provider Details

I. General information

NPI: 1801684196
Provider Name (Legal Business Name): MACKENZIE ANN LIBERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W BROADWAY
BOSTON MA
02127-2245
US

IV. Provider business mailing address

409 W BROADWAY
BOSTON MA
02127-2245
US

V. Phone/Fax

Practice location:
  • Phone: 617-269-7500
  • Fax:
Mailing address:
  • Phone: 617-269-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2390273
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2390273
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: