=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922446889
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MACKENZIE E DOUGLASS MSN, CNM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2013
-----------------------------------------------------
Last Update Date | 07/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1505 SOQUEL DR STE 1
-----------------------------------------------------
City | SANTA CRUZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95065-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-465-5440
-----------------------------------------------------
Fax | 831-462-2017
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 DATA DR ATTN CREDENTIALING/PAYER ENROLLMENT
-----------------------------------------------------
City | RANCHO CORDOVA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95670-7956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | APRN.CNM.019342
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | 209.010345
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | 95212458
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------