Healthcare Provider Details

I. General information

NPI: 1306584339
Provider Name (Legal Business Name): MACKENZIE CHRISTINE LYTTLE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACKENZIE DAVIDGE PT, DPT

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 W SERVICE DR
WINONA MN
55987-2540
US

IV. Provider business mailing address

1446 SUPERIOR ST
ONALASKA WI
54650-2088
US

V. Phone/Fax

Practice location:
  • Phone: 507-474-6900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12603
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: