Healthcare Provider Details

I. General information

NPI: 1982292926
Provider Name (Legal Business Name): MACKINZIE LEE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 UNIVERSITY BLVD STE 8
JACKSON MS
39204-3907
US

IV. Provider business mailing address

4985 SPRINGRIDGE RD
RAYMOND MS
39154-9492
US

V. Phone/Fax

Practice location:
  • Phone: 601-502-4245
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number886202
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904736
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: