Healthcare Provider Details

I. General information

NPI: 1205755790
Provider Name (Legal Business Name): MACKENZIE RUTGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1853 R W BERENDS DR SW
WYOMING MI
49519-4955
US

IV. Provider business mailing address

4507 E SUMMIT WOODS DR NE
ROCKFORD MI
49341-7672
US

V. Phone/Fax

Practice location:
  • Phone: 616-534-9301
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704405874
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: