Provider Demographics
NPI:1225523004
Name:MACK, ALICIA MAE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:MAE
Last Name:MACK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MISS
Other - First Name:ALICIA
Other - Middle Name:MAE
Other - Last Name:ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:212 S. 4TH ST. SUITE 301
Mailing Address - Street 2:SPECTRA HEALTH
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-757-2100
Mailing Address - Fax:701-757-2813
Practice Address - Street 1:212 S. 4TH ST. SUITE 301
Practice Address - Street 2:SPECTRA HEALTH
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-757-2100
Practice Address - Fax:701-757-2813
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2344340163W00000X
NDR39910163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse