Basic Information
| Provider Information | |||||||||
| NPI: | 1801356902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACKENZIE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DAVIS | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176335555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5939 HARRY HINES BOULEVARD 7TH FLOOR SUITE 700 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753908987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146451919 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2019 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP140748 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | AP140748 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.