Provider Demographics
NPI:1528560513
Name:MACK, RICKEY EDNA (CNP)
Entity Type:Individual
Prefix:
First Name:RICKEY
Middle Name:EDNA
Last Name:MACK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 AIRPORT RD STE D
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-8184
Mailing Address - Country:US
Mailing Address - Phone:501-625-7500
Mailing Address - Fax:501-625-7777
Practice Address - Street 1:120 ADCOCK RD STE D
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-7958
Practice Address - Country:US
Practice Address - Phone:501-547-5961
Practice Address - Fax:501-651-4296
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005560363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health