Provider Demographics
NPI:1316813165
Name:BOLLS, MACKENZIE KAYTLYNN
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:KAYTLYNN
Last Name:BOLLS
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 1:310 N MOUNT SHASTA BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2352
Mailing Address - Country:US
Mailing Address - Phone:530-524-9661
Mailing Address - Fax:
Practice Address - Street 1:310 N MOUNT SHASTA BLVD STE 5
Practice Address - Street 2:STE 5
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2352
Practice Address - Country:US
Practice Address - Phone:530-524-9661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker