Provider Demographics
NPI:1134483498
Name:MACK, KASSANDRA MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:MICHELLE
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 1:11 WINDWOOD CTS
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-2573
Mailing Address - Country:US
Mailing Address - Phone:716-986-1006
Mailing Address - Fax:
Practice Address - Street 1:11 WINDWOOD CTS
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-2573
Practice Address - Country:US
Practice Address - Phone:716-986-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-01
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303962164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse