Provider Demographics
NPI:1114573409
Name:MACK, MIA ANN
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:ANN
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 BUCHANAN STNE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017
Mailing Address - Country:US
Mailing Address - Phone:202-710-4557
Mailing Address - Fax:
Practice Address - Street 1:1751 STANTON TER SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-2823
Practice Address - Country:US
Practice Address - Phone:202-907-5698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant