Provider Demographics
NPI:1538676549
Name:MACK, TANYA ROSE (RN)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:ROSE
Last Name:MACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:ROSE
Other - Last Name:AUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2592 KWINA RD
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9278
Mailing Address - Country:US
Mailing Address - Phone:360-384-0464
Mailing Address - Fax:360-384-2336
Practice Address - Street 1:2592 KWINA RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9278
Practice Address - Country:US
Practice Address - Phone:360-384-0464
Practice Address - Fax:360-384-2336
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60209378163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn