Basic Information
| Provider Information | |||||||||
| NPI: | 1760005409 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NUNNALLY | ||||||||
| FirstName: | MACKENZIE | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1377 MOTOR PKWY STE 307 | ||||||||
| Address2: | |||||||||
| City: | ISLANDIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117495258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315805200 | ||||||||
| FaxNumber: | 6315805222 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 FESTIVAL PARK PLZ | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238314449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049308280 | ||||||||
| FaxNumber: | 8049308101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2020 | ||||||||
| LastUpdateDate: | 05/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2204000512 | VA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.