Provider Demographics
NPI:1164118790
Name:MACK, TDENISE
Entity Type:Individual
Prefix:
First Name:TDENISE
Middle Name:
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 1:200 TURNING TREE RD
Mailing Address - Street 2:
Mailing Address - City:WILMER
Mailing Address - State:TX
Mailing Address - Zip Code:75172-1502
Mailing Address - Country:US
Mailing Address - Phone:469-988-9343
Mailing Address - Fax:
Practice Address - Street 1:200 TURNING TREE RD
Practice Address - Street 2:
Practice Address - City:WILMER
Practice Address - State:TX
Practice Address - Zip Code:75172-1502
Practice Address - Country:US
Practice Address - Phone:469-988-9343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide