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General NPI Number Information
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NPI Number | 1407610017
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Entity Type | Individual
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Provider Name | MACKENZIE BROOKE RUSSELL PA-C
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Gender | Female
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Dates
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Enumeration Date | 02/13/2024
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Last Update Date | 10/10/2025
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Provider Practice Location Address
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Address Line | 25 HOSPITAL CENTER CMNS STE 200
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City | HILTON HEAD ISLAND
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State | SC
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Zip | 29926-2841
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Country | US
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Telephone | 843-837-4400
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Fax | 843-837-4440
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Provider Business Mailing Address
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Address Line | PO BOX 2330
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City | BLUFFTON
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State | SC
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Zip | 29910-2330
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Country | US
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Telephone | 843-837-4400
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Fax | 843-837-4440
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 6039
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License Number State | SC
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