Healthcare Provider Details

I. General information

NPI: 1144077132
Provider Name (Legal Business Name): MACKENZIE VANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 BIELENBERG DR STE 102-104
WOODBURY MN
55125-1700
US

IV. Provider business mailing address

177 MIDWEST AVE N
LAKE ELMO MN
55042-9663
US

V. Phone/Fax

Practice location:
  • Phone: 612-439-4653
  • Fax:
Mailing address:
  • Phone: 651-353-5530
  • 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: