Provider Demographics
NPI:1972243749
Name:MASTRUD, MACKENNA RAE (LAC)
Entity type:Individual
Prefix:
First Name:MACKENNA
Middle Name:RAE
Last Name:MASTRUD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2939 SW SPRING GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3946
Mailing Address - Country:US
Mailing Address - Phone:971-350-9148
Mailing Address - Fax:
Practice Address - Street 1:2939 SW SPRING GARDEN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-3946
Practice Address - Country:US
Practice Address - Phone:971-350-9148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC209770171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist