Healthcare Provider Details

I. General information

NPI: 1205654027
Provider Name (Legal Business Name): MACKENZIE LEIGH GALE CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 W GRAND ST
SPRINGFIELD MO
65802-4802
US

IV. Provider business mailing address

2704 N 29TH ST
OZARK MO
65721-8464
US

V. Phone/Fax

Practice location:
  • Phone: 417-831-0150
  • Fax:
Mailing address:
  • Phone: 417-350-8016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number2001014349
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2024040091
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: