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General NPI Number Information
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NPI Number | 1760084552
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Entity Type | Individual
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Provider Name | MACKENZIE UNDERWOOD ATC
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Gender | Female
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Dates
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Enumeration Date | 11/16/2020
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Last Update Date | 11/16/2020
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Provider Practice Location Address
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Address Line | 12345 E 21ST ST N
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City | WICHITA
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State | KS
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Zip | 67206-3503
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Country | US
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Telephone | 316-634-0909
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Fax |
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Provider Business Mailing Address
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Address Line | 1942 N WOOD CT
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City | WICHITA
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State | KS
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Zip | 67212-5321
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Country | US
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Telephone | 316-633-3433
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 24-00789
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License Number State | KS
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