Provider Demographics
NPI:1629888938
Name:BLOXHAM, MACKENZIE (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:BLOXHAM
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 E VETERANS DR APT B101
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4699
Mailing Address - Country:US
Mailing Address - Phone:435-512-0372
Mailing Address - Fax:
Practice Address - Street 1:1 WILLIAM L JONES DR
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38505-0001
Practice Address - Country:US
Practice Address - Phone:931-372-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT20000519892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty