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General NPI Number Information
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NPI Number | 1891205373
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Entity Type | Individual
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Provider Name | MACKENZIE LURENE MASHBURN GRILLO NP
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Gender | Female
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Dates
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Enumeration Date | 10/10/2017
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Last Update Date | 10/10/2017
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Provider Practice Location Address
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Address Line | 8954 HOSPITAL DR
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-2272
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Country | US
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Telephone | 678-640-5023
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Fax |
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Provider Business Mailing Address
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Address Line | 3316 HIGH NOONTIDE WAY NW
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City | ACWORTH
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State | GA
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Zip | 30101-6967
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Country | US
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Telephone | 678-640-5023
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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 | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | RN191815
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License Number State | GA
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