Provider Demographics
NPI:1396331302
Name:PONNAPALLI, MACKENZIE (AG-CNS)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:PONNAPALLI
Suffix:
Gender:F
Credentials:AG-CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 W GRAND PKWY N STE 130
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77493-2711
Mailing Address - Country:US
Mailing Address - Phone:281-392-3401
Mailing Address - Fax:
Practice Address - Street 1:7200 CAMBRIDGE ST FL 6
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4202
Practice Address - Country:US
Practice Address - Phone:713-798-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1012648364S00000X, 364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology