=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619775632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MACKENZIE LYNCH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2025
-----------------------------------------------------
Last Update Date | 03/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2130 E JACKSON BLVD
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63755-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-243-8408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 226 S MESSMER ST
-----------------------------------------------------
City | SCOTT CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63780-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 2025006360
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------