Provider Demographics
NPI:1427612696
Name:SIPES, MACKENZIE TAYLOR (LPN)
Entity type:Individual
Prefix:MRS
First Name:MACKENZIE
Middle Name:TAYLOR
Last Name:SIPES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1672 PARK AVE E
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44905-2916
Mailing Address - Country:US
Mailing Address - Phone:419-632-4670
Mailing Address - Fax:
Practice Address - Street 1:1672 PARK AVE E
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44905-2916
Practice Address - Country:US
Practice Address - Phone:419-632-4670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH163353164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH163353Medicaid