Provider Demographics
NPI:1003061839
Name:MACK, TRUDY JOHNETTE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:TRUDY
Middle Name:JOHNETTE
Last Name:MACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 N. WATER STREET
Mailing Address - Street 2:APT. 205
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14604
Mailing Address - Country:US
Mailing Address - Phone:585-286-0097
Mailing Address - Fax:
Practice Address - Street 1:165 N. WATER STREET
Practice Address - Street 2:APT. 205
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14604
Practice Address - Country:US
Practice Address - Phone:585-286-0097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284904164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse