Provider Demographics
NPI:1427231927
Name:TAYLOR MACK, VIRGINIA HICKS (RN)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:HICKS
Last Name:TAYLOR 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 1:537 FLINT RIVER COURT
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238
Mailing Address - Country:US
Mailing Address - Phone:770-472-9917
Mailing Address - Fax:
Practice Address - Street 1:265 BOULEVARD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1208
Practice Address - Country:US
Practice Address - Phone:404-730-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN178733101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)