Provider Demographics
NPI:1558149633
Name:STILLWELL MACK, SHIRLEY (LVN)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:STILLWELL MACK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1832 ARBUCKLE WAY
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-1340
Mailing Address - Country:US
Mailing Address - Phone:661-470-0879
Mailing Address - Fax:
Practice Address - Street 1:1832 ARBUCKLE WAY
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-1340
Practice Address - Country:US
Practice Address - Phone:661-470-0879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA271191164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty