Provider Demographics
NPI:1104247493
Name:WANN, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:WANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 WHITMAN AVE N
Mailing Address - Street 2:APT. #41
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-7848
Mailing Address - Country:US
Mailing Address - Phone:919-621-9292
Mailing Address - Fax:
Practice Address - Street 1:3921 WHITMAN AVE N
Practice Address - Street 2:41
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-7848
Practice Address - Country:US
Practice Address - Phone:919-621-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist