Healthcare Provider Details

I. General information

NPI: 1386462455
Provider Name (Legal Business Name): KIRA ANN MACKAY PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2024
Last Update Date: 09/28/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 MAIN ST S
MINOT ND
58701-3914
US

IV. Provider business mailing address

603 11TH ST NW
MINOT ND
58703-2159
US

V. Phone/Fax

Practice location:
  • Phone: 701-852-5070
  • Fax: 877-712-6895
Mailing address:
  • Phone: 701-340-5236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201114
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: