Provider Demographics
NPI:1699403543
Name:MELLUM, MACKENZIE MARIE (PA)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MARIE
Last Name:MELLUM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21260 CHIPPENDALE AVE W
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-1427
Mailing Address - Country:US
Mailing Address - Phone:651-463-7181
Mailing Address - Fax:651-241-0829
Practice Address - Street 1:21260 CHIPPENDALE AVE W
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-1427
Practice Address - Country:US
Practice Address - Phone:651-463-7181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant