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General NPI Number Information
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NPI Number | 1336891449
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Entity Type | Individual
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Provider Name | MACKENZIE LEIGH CUCANCIC RN
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Gender | Female
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Dates
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Enumeration Date | 01/20/2022
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Last Update Date | 04/20/2022
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Provider Practice Location Address
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Address Line | 494 SPRINGHILL ST STE 100
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City | JASPER
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State | TX
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Zip | 75951-5055
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Country | US
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Telephone | 936-715-7199
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Fax |
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Provider Business Mailing Address
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Address Line | 612 W WOODLAND ST
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City | KIRBYVILLE
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State | TX
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Zip | 75956-1538
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Country | US
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Telephone | 936-715-7199
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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 | 883819
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2021210317
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License Number State | TX
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