Provider Demographics
NPI:1386254878
Name:KURTH, MACKENZIE ANN (PA-C)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANN
Last Name:KURTH
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:DAINTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 505673
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3525 E BATTLEFIELD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-3435
Practice Address - Country:US
Practice Address - Phone:417-269-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-09
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022042504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant