=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790463495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MACKENZIE JAMES STANLEY NURSE PRACTITIONER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2023
-----------------------------------------------------
Last Update Date | 07/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 DRIVING PARK AVE
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14513-1090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-332-2022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 DRIVING PARK AVE
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14513-1090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-332-2022
-----------------------------------------------------
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 | F352011
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------