Healthcare Provider Details

I. General information

NPI: 1376294389
Provider Name (Legal Business Name): MACKENZIE RAE WEILAND MSN, WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 32ND ST
EVERETT WA
98201-4302
US

IV. Provider business mailing address

17202 AURORA AVE N APT 223
SHORELINE WA
98133-5354
US

V. Phone/Fax

Practice location:
  • Phone: 800-769-0045
  • Fax:
Mailing address:
  • Phone: 502-715-2696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN61239218
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN297783
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP61258631
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: