Provider Demographics
NPI:1285185694
Name:MACK, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:RADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:PO BOX 152
Mailing Address - Street 2:
Mailing Address - City:RYE
Mailing Address - State:CO
Mailing Address - Zip Code:81069-0152
Mailing Address - Country:US
Mailing Address - Phone:719-248-1745
Mailing Address - Fax:
Practice Address - Street 1:2773 APPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:COLORADO CITY
Practice Address - State:CO
Practice Address - Zip Code:81019
Practice Address - Country:US
Practice Address - Phone:719-248-1745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONA. 00767599376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide