Provider Demographics
NPI:1265489652
Name:MACK, ALLISON J (CNP)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:J
Last Name:MACK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:ML 2011
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4506
Mailing Address - Fax:513-636-7247
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 2011
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4506
Practice Address - Fax:513-636-7247
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.06918363L00000X, 363LF0000X
OHNP06918363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78014909Medicaid
OH2411867Medicaid
KY78014909Medicaid
OHMANP13171Medicare PIN