Healthcare Provider Details

I. General information

NPI: 1558112409
Provider Name (Legal Business Name): MACKENZIE WIDMAIER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MACKENZIE CLARK CRNA

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-9800
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6621
  • Fax: 570-271-6762
Mailing address:
  • Phone: 570-271-6621
  • Fax: 570-271-6762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN708029
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: