Provider Demographics
NPI:1275296055
Name:MACK, LILLIAN CHRISTINE (APRN)
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:CHRISTINE
Last Name:MACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1095
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32802-1095
Mailing Address - Country:US
Mailing Address - Phone:407-450-6925
Mailing Address - Fax:
Practice Address - Street 1:1426 WILLOW BRANCH DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7457
Practice Address - Country:US
Practice Address - Phone:386-216-9223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11015887363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care