Individual
ELISE VANETT MACKENZIE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
P.T.
Contact information
Practice address
1570 BEAM AVE, MAPLEWOOD, MN 55109-1166
(651) 326-7940
Mailing address
6721 MADISON ST NE, FRIDLEY, MN 55432-4450
(651) 864-0712
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
1996
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
652S6MC
BCBS
MN
Enumeration date
11/01/2006
Last updated
07/08/2007
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