Healthcare Provider Details

I. General information

NPI: 1336715192
Provider Name (Legal Business Name): MACKENZIE LEIGH SHATTUCK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MACKENZIE ROBSON

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7335 WESTSHIRE DR STE 102
LANSING MI
48917-9703
US

IV. Provider business mailing address

804 SERVICE RD STE A202
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-662-1012
  • Fax: 517-622-1033
Mailing address:
  • Phone: 517-622-1012
  • Fax: 517-622-1033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101028121
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: