Healthcare Provider Details

I. General information

NPI: 1578183067
Provider Name (Legal Business Name): MACKENZIE TRAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1924 ALCOA HWY
KNOXVILLE TN
37920-1511
US

IV. Provider business mailing address

1852 CHEROKEE BLUFF DR
KNOXVILLE TN
37920-2215
US

V. Phone/Fax

Practice location:
  • Phone: 865-305-9000
  • Fax:
Mailing address:
  • Phone: 615-587-4935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number30846
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number216365
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: