Healthcare Provider Details

I. General information

NPI: 1902589310
Provider Name (Legal Business Name): MACKENZIE RAE HAUSER-CREWS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WHITAKER RIDGE DR
WINSTON SALEM NC
27106-4966
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-718-8000
  • Fax: 336-718-8011
Mailing address:
  • Phone: 336-718-8000
  • Fax: 336-718-8011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5018746
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5018746
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number304336
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: