Healthcare Provider Details

I. General information

NPI: 1013555887
Provider Name (Legal Business Name): MACKENZIE SNORTUM PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 1ST ST E STE 5
PARK RAPIDS MN
56470-1764
US

IV. Provider business mailing address

20122 239TH AVE
NEVIS MN
56467-4209
US

V. Phone/Fax

Practice location:
  • Phone: 320-321-9599
  • Fax: 877-962-3624
Mailing address:
  • Phone: 320-321-9599
  • Fax: 877-962-3624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2019073975
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: