Basic Information
| Provider Information | |||||||||
| NPI: | 1770147688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AINSWORTH | ||||||||
| FirstName: | MACKENZIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 740020 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303740020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2130 SW 59TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731197025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053037555 | ||||||||
| FaxNumber: | 4055615615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2019 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R0118628 | OK | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 118628 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200895920 | 05 | OK | MEDICAID |