Provider Demographics
NPI:1194423251
Name:BANCROFT, MACKENZIE ANN
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANN
Last Name:BANCROFT
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 1:211 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-6117
Mailing Address - Country:US
Mailing Address - Phone:207-877-3400
Mailing Address - Fax:207-877-3401
Practice Address - Street 1:211 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6117
Practice Address - Country:US
Practice Address - Phone:207-877-3400
Practice Address - Fax:207-877-3401
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2650363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program