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General NPI Number Information
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NPI Number | 1669213963
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Entity Type | Individual
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Provider Name | MACKENZIE GRACE SHIELDS
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Gender | Female
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Dates
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Enumeration Date | 06/03/2024
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Last Update Date | 06/03/2024
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Provider Practice Location Address
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Address Line | 4419 TRAM RD
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City | PANAMA CITY
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State | FL
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Zip | 32404-2559
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Country | US
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Telephone | 850-747-5401
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Fax |
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Provider Business Mailing Address
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Address Line | 1089 OVERPASS RD
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City | COTTONDALE
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State | FL
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Zip | 32431-8943
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Country | US
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Telephone | 850-718-7624
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTAT33491
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License Number State | FL
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