Provider Demographics
NPI:1235379595
Name:MACK, AKIYA SHANT'E (LPN)
Entity Type:Individual
Prefix:MS
First Name:AKIYA
Middle Name:SHANT'E
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 1:64 MOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-2845
Mailing Address - Country:US
Mailing Address - Phone:516-771-3749
Mailing Address - Fax:
Practice Address - Street 1:64 MOUNT AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-2845
Practice Address - Country:US
Practice Address - Phone:516-771-3749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295722164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse