Provider Demographics
NPI:1104636547
Name:WEIS, MACKENZIE J
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:J
Last Name:WEIS
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 1:306 149TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MN
Mailing Address - Zip Code:55382-9140
Mailing Address - Country:US
Mailing Address - Phone:320-291-0229
Mailing Address - Fax:
Practice Address - Street 1:306 149TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MN
Practice Address - Zip Code:55382-9140
Practice Address - Country:US
Practice Address - Phone:320-291-0229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program