=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194554352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MACKENZIE O'HARA ANDERSON NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2024
-----------------------------------------------------
Last Update Date | 11/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 685 CITADEL DR E STE 505
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80909-5372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-265-4412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 685 CITADEL DR E STE 505
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80909-5372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-265-4412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WM0102X
-----------------------------------------------------
Taxonomy Name | Maternal Newborn Registered Nurse
-----------------------------------------------------
License Number | RN.1698237
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | APN.0999982-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APN.0999982-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------