Provider Demographics
NPI:1467705392
Name:MACK, KYLIE L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KYLIE
Middle Name:L
Last Name:MACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 DELNOR DR #100
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134
Mailing Address - Country:US
Mailing Address - Phone:630-262-1001
Mailing Address - Fax:630-262-8065
Practice Address - Street 1:351 DELNOR DR #100
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134
Practice Address - Country:US
Practice Address - Phone:630-262-1001
Practice Address - Fax:630-262-8065
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004411363A00000X
IL085.004411363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical