Individual
MACKENZEE DERRICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
AGACNP-BC
Contact information
Practice address
3289 N MAYFAIR RD, WAUWATOSA, WI 53222-3203
(414) 771-7900
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(800) 326-2250
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
8553
WI
363LA2100X
Acute Care Nurse Practitioner
8553-33
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100080985
—
WI
Enumeration date
08/05/2018
Last updated
01/09/2025
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