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General NPI Number Information
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NPI Number | 1154264414
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Entity Type | Individual
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Provider Name | MACKENZIE CLARK RN
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Gender | Female
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Dates
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Enumeration Date | 04/13/2026
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Last Update Date | 04/13/2026
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Provider Practice Location Address
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Address Line | 100 N MARIO CAPECCHI DR
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City | SALT LAKE CITY
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State | UT
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Zip | 84113-1103
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Country | US
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Telephone | 425-749-9723
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 944
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City | LOPEZ ISLAND
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State | WA
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Zip | 98261-0944
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 13601045-3102
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License Number State | UT
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