Healthcare Provider Details

I. General information

NPI: 1063674554
Provider Name (Legal Business Name): KATHERINE JOAN MACKENZIE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 HAARFAGER AVE N
CANBY MN
56220-1223
US

IV. Provider business mailing address

308 HAARFAGER AVE N
CANBY MN
56220-1223
US

V. Phone/Fax

Practice location:
  • Phone: 828-777-3203
  • Fax:
Mailing address:
  • Phone: 828-777-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6322
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: