Provider Demographics
NPI:1346748837
Name:MACK, KAKETHIA S (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:KAKETHIA
Middle Name:S
Last Name:MACK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4124 BOSENBERRY WAY
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-4265
Mailing Address - Country:US
Mailing Address - Phone:678-463-6568
Mailing Address - Fax:
Practice Address - Street 1:4124 BOSENBERRY WAY
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294
Practice Address - Country:US
Practice Address - Phone:678-463-6568
Practice Address - Fax:678-463-6568
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN154797363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily