Healthcare Provider Details

I. General information

NPI: 1134895642
Provider Name (Legal Business Name): MACKENZIE EILEEN CALLIS APRN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18650 SW BOONES FERRY RD STE 3
TUALATIN OR
97062-8491
US

IV. Provider business mailing address

PO BOX 2214
HOMER AK
99603-2214
US

V. Phone/Fax

Practice location:
  • Phone: 503-351-5858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number180541
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202107871NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: