Provider Demographics
NPI:1194555128
Name:BEACOM, MACKENZIE RAE (APRN, CPNP)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RAE
Last Name:BEACOM
Suffix:
Gender:F
Credentials:APRN, CPNP
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:VANBUSKIRK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5875 TEAKWOOD LN N APT B
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-1590
Mailing Address - Country:US
Mailing Address - Phone:651-336-7586
Mailing Address - Fax:
Practice Address - Street 1:345 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2346
Practice Address - Country:US
Practice Address - Phone:651-220-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11806363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics