Provider Demographics
NPI:1336715192
Name:SHATTUCK, MACKENZIE LEIGH (DO)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LEIGH
Last Name:SHATTUCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:ROBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD STE A202
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-622-1012
Mailing Address - Fax:517-622-1033
Practice Address - Street 1:7335 WESTSHIRE DR STE 102
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-9703
Practice Address - Country:US
Practice Address - Phone:517-662-1012
Practice Address - Fax:517-622-1033
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101028121208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics