Healthcare Provider Details

I. General information

NPI: 1114881091
Provider Name (Legal Business Name): MACKENZIE RAE SERGEON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 STATE ST
GASSAWAY WV
26624-1132
US

IV. Provider business mailing address

64 STATE ST
GASSAWAY WV
26624-1132
US

V. Phone/Fax

Practice location:
  • Phone: 304-651-1063
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number42331
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: