Healthcare Provider Details

I. General information

NPI: 1619629532
Provider Name (Legal Business Name): MACKENZIE FAY FORD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E SHERMAN BLVD
MUSKEGON MI
49444-1849
US

IV. Provider business mailing address

800 E ELLIS RD # 571
NORTON SHORES MI
49441-5622
US

V. Phone/Fax

Practice location:
  • Phone: 231-672-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010988
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: