Healthcare Provider Details

I. General information

NPI: 1346793445
Provider Name (Legal Business Name): MCKENZIE MACK LAKE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 BROADMOOR BLVD NE
RIO RANCHO NM
87144-2100
US

IV. Provider business mailing address

2225 DELFINIO DR SE
RIO RANCHO NM
87124-2947
US

V. Phone/Fax

Practice location:
  • Phone: 505-550-9863
  • Fax:
Mailing address:
  • Phone: 505-550-9863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02964
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: