Provider Demographics
NPI:1275961963
Name:MACK, RACHEL THERESE (NP)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:THERESE
Last Name:MACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:THERESE
Other - Last Name:SHINEVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR STE J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:5301 MCAULEY DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-3327
Practice Address - Fax:734-712-5525
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6972253-8900363L00000X
MI4704316510363L00000X, 363LN0000X
IDNP-1529A363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner