Provider Demographics
NPI:1528393303
Name:MACK, ANNETTE (LPN)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6909 S 38TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-6195
Mailing Address - Country:US
Mailing Address - Phone:602-446-8474
Mailing Address - Fax:
Practice Address - Street 1:6909 S 38TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6195
Practice Address - Country:US
Practice Address - Phone:602-446-8474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP041359164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLP041359OtherLICENSE