Provider Demographics
NPI:1528573458
Name:MACK, NANCY ANN (OTR)
Entity Type:Individual
Prefix:MISS
First Name:NANCY
Middle Name:ANN
Last Name:MACK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11409 RIDGEMOUNT AVE W
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1455
Mailing Address - Country:US
Mailing Address - Phone:651-328-3107
Mailing Address - Fax:
Practice Address - Street 1:295 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-2400
Practice Address - Country:US
Practice Address - Phone:651-254-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105421225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist