Basic Information
| Provider Information | |||||||||
| NPI: | 1497820062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACKENZIE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859222575 | ||||||||
| FaxNumber: | 5859225033 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859222575 | ||||||||
| FaxNumber: | 5859225033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 08/25/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 380528 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02795393 | 05 | NY | MEDICAID |