Provider Demographics
NPI:1225279524
Name:MACK, MARQUITA D (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARQUITA
Middle Name:D
Last Name:MACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:MARQUITA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:535 STOCKBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1707
Mailing Address - Country:US
Mailing Address - Phone:716-510-6369
Mailing Address - Fax:
Practice Address - Street 1:535 STOCKBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1707
Practice Address - Country:US
Practice Address - Phone:716-894-5462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276635-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse