Provider Demographics
NPI:1386031094
Name:MACK, NICOLE M
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:618 W ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-4225
Mailing Address - Country:US
Mailing Address - Phone:769-251-3329
Mailing Address - Fax:
Practice Address - Street 1:618 W ACADEMY ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4225
Practice Address - Country:US
Practice Address - Phone:769-251-3329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372600000XNursing Service Related ProvidersAdult Companion