Provider Demographics
NPI:1558749267
Name:MACK, ZELBESA VAILIIDA DAKUE (CRNP)
Entity Type:Individual
Prefix:
First Name:ZELBESA
Middle Name:VAILIIDA DAKUE
Last Name:MACK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 HADDINGTON RD
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-5719
Mailing Address - Country:US
Mailing Address - Phone:410-961-0844
Mailing Address - Fax:
Practice Address - Street 1:28 HADDINGTON RD
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-5719
Practice Address - Country:US
Practice Address - Phone:410-961-0844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR137492363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner