Basic Information
| Provider Information | |||||||||
| NPI: | 1518499516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN ZYL | ||||||||
| FirstName: | CELYSSE | ||||||||
| MiddleName: | MACKEY | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | MACKEY | ||||||||
| OtherFirstName: | CELYSSE | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 310 S LIMESTONE STE A1A | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405083008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592573573 | ||||||||
| FaxNumber: | 8593230096 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 S LIMESTONE STE A1A | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405083008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592573573 | ||||||||
| FaxNumber: | 8593230096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2017 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208100000X | 04689 | KY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.