Provider Demographics
NPI:1326606682
Name:MACK, TONIA (RN)
Entity Type:Individual
Prefix:
First Name:TONIA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 LITTLE TORCH ST
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-1109
Mailing Address - Country:US
Mailing Address - Phone:561-255-3496
Mailing Address - Fax:
Practice Address - Street 1:2029 LITTLE TORCH ST
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-1109
Practice Address - Country:US
Practice Address - Phone:561-255-3496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9168871163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse