MEDICARE: MACKENZIE PONNAPALLI AG-CNS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364S00000X	Clinical Nurse Specialist	1012648	TX
2	364SG0600X	Gerontology Clinical Nurse Specialist	1012648	TX

General Provider Information

NPI Number	:	1396331302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE PONNAPALLI AG-CNS

Provider Business Mailing Address
First Line	:	1331 W GRAND PKWY N STE 130
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77493-2711
Country	:	US
Telephone Number	:	281-646-9000
Fax Number	:	281-206-2311

Provider Business Practice Location Address
First Line	:	7200 CAMBRIDGE ST FL 6
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-4202
Country	:	US
Telephone Number	:	713-798-2545
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2020
Last Update Date	:	10/23/2025

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