Healthcare Provider Details

I. General information

NPI: 1881502052
Provider Name (Legal Business Name): MACKENZIE CATHERINE LANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 SOUTH NEW STREET
WEST CHESTER PA
19383-0001
US

IV. Provider business mailing address

20 WOODWARD DR
WILMINGTON DE
19808-4342
US

V. Phone/Fax

Practice location:
  • Phone: 302-547-4760
  • Fax:
Mailing address:
  • Phone: 302-547-4760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2152930
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: