Provider Demographics
NPI:1124224142
Name:MACK, ESSIE B (MT)
Entity Type:Individual
Prefix:MS
First Name:ESSIE
Middle Name:B
Last Name:MACK
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1567 S RANGE AVE
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-5201
Mailing Address - Country:US
Mailing Address - Phone:225-665-3500
Mailing Address - Fax:225-665-3518
Practice Address - Street 1:1567 S RANGE AVE
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-5201
Practice Address - Country:US
Practice Address - Phone:225-665-3500
Practice Address - Fax:225-665-3518
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACLP.G00606-GEN246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist