Healthcare Provider Details

I. General information

NPI: 1790463495
Provider Name (Legal Business Name): MACKENZIE JAMES STANLEY NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601B W WASHINGTON ST
GENEVA NY
14456-2119
US

IV. Provider business mailing address

601B W WASHINGTON ST
GENEVA NY
14456-2119
US

V. Phone/Fax

Practice location:
  • Phone: 315-781-8448
  • Fax:
Mailing address:
  • Phone: 315-787-8151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF352011
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: