Healthcare Provider Details

I. General information

NPI: 1518821040
Provider Name (Legal Business Name): MAKENNA LEE ROYALLE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 1ST AVE NE STE 2
AUSTIN MN
55912-3401
US

IV. Provider business mailing address

3101 SUPERIOR DR NW
ROCHESTER MN
55901-1993
US

V. Phone/Fax

Practice location:
  • Phone: 507-292-1006
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: