Provider Demographics
NPI:1497254502
Name:MACK, NIA'JA STE'VONA (FNP-C)
Entity Type:Individual
Prefix:
First Name:NIA'JA
Middle Name:STE'VONA
Last Name:MACK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25627 BUFFWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-5994
Mailing Address - Country:US
Mailing Address - Phone:225-305-3828
Mailing Address - Fax:
Practice Address - Street 1:100 WOMANS WAY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-5100
Practice Address - Country:US
Practice Address - Phone:225-924-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-04
Last Update Date:2018-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09772363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily