Provider Demographics
NPI:1386472579
Name:RILEY, MACKENZIE HARRIS
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:HARRIS
Last Name:RILEY
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 1:132 CANARD CT
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-2676
Mailing Address - Country:US
Mailing Address - Phone:318-957-9100
Mailing Address - Fax:
Practice Address - Street 1:132 CANARD CT
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-2676
Practice Address - Country:US
Practice Address - Phone:318-957-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201456163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse