Healthcare Provider Details

I. General information

NPI: 1528944782
Provider Name (Legal Business Name): MACKENZIE NICOLE WAUGH APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2025
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 COMFORT DR
REEDSVILLE WV
26547-1401
US

IV. Provider business mailing address

PO BOX 780
MORGANTOWN WV
26507-0780
US

V. Phone/Fax

Practice location:
  • Phone: 304-864-0006
  • Fax: 304-864-0015
Mailing address:
  • Phone: 304-285-7101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number123908
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: