Provider Demographics
NPI:1194554352
Name:ANDERSON, MACKENZIE O'HARA (NP)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:O'HARA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 CITADEL DR E STE 505
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5372
Mailing Address - Country:US
Mailing Address - Phone:719-265-4412
Mailing Address - Fax:
Practice Address - Street 1:685 CITADEL DR E STE 505
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5372
Practice Address - Country:US
Practice Address - Phone:719-265-4412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1698237163WM0102X
COAPN.0999982-NP363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health