Provider Demographics
NPI:1124106091
Name:MACKENZIE, ELISE VANETT (PT)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:VANETT
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6721 MADISON ST NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-4450
Mailing Address - Country:US
Mailing Address - Phone:651-864-0712
Mailing Address - Fax:
Practice Address - Street 1:1570 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1166
Practice Address - Country:US
Practice Address - Phone:651-326-7940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1996225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN652S6MCOtherBCBS