Provider Demographics
NPI:1679380596
Name:PEMBERTON, MACKENZIE NICOLE (EMT, CPSS)
Entity type:Individual
Prefix:MISS
First Name:MACKENZIE
Middle Name:NICOLE
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:EMT, CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 PROFESSIONAL DR STE D4
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3636
Mailing Address - Country:US
Mailing Address - Phone:810-496-4937
Mailing Address - Fax:
Practice Address - Street 1:1063 PROFESSIONAL DR STE D4
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3636
Practice Address - Country:US
Practice Address - Phone:810-496-4937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist