Provider Demographics
NPI:1073548798
Name:MACK, NANCY LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:LYNN
Last Name:MACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15126 N. CHESAPEAKE RD
Mailing Address - Street 2:
Mailing Address - City:MEAD
Mailing Address - State:WA
Mailing Address - Zip Code:99021
Mailing Address - Country:US
Mailing Address - Phone:509-279-2644
Mailing Address - Fax:
Practice Address - Street 1:711 S COWLEY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1330
Practice Address - Country:US
Practice Address - Phone:509-473-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00009988225100000X
CA21016225100000X
WAPT00009988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist