Healthcare Provider Details

I. General information

NPI: 1760986772
Provider Name (Legal Business Name): MACKENZIE ALEXANDRA PIATKA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 ANKENEY RD
XENIA OH
45385-9533
US

IV. Provider business mailing address

1140 ANKENEY RD
XENIA OH
45385-9533
US

V. Phone/Fax

Practice location:
  • Phone: 937-301-2735
  • Fax:
Mailing address:
  • Phone: 937-301-2735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: