Provider Demographics
NPI:1326211624
Name:MACK, KATHLEEN ANN (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:MACK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 VANDERDASSON RD
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-8880
Mailing Address - Country:US
Mailing Address - Phone:208-944-1537
Mailing Address - Fax:208-944-6067
Practice Address - Street 1:1006 VANDERDASSON RD
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-8880
Practice Address - Country:US
Practice Address - Phone:208-944-1537
Practice Address - Fax:208-944-6067
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00106768163WP0808X
UT8636044-4405363LF0000X
WAAP30008033363LP0808X
ID73858363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health