Healthcare Provider Details

I. General information

NPI: 1386020063
Provider Name (Legal Business Name): RONNIE SUE MACKIE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RONNIE SUE DEARDEN RN

II. Dates (important events)

Enumeration Date: 08/05/2015
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 HIGH ST SUITE 201
MILTON MA
02186
US

IV. Provider business mailing address

156 LANSDOWNE ST
QUINCY MA
02171
US

V. Phone/Fax

Practice location:
  • Phone: 617-594-2300
  • Fax:
Mailing address:
  • Phone: 617-594-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN234540
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN234540
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberCNPRN234540
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCNPRN234540
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: