Provider Demographics
NPI:1568019016
Name:MACKEY, NICKOLE
Entity Type:Individual
Prefix:
First Name:NICKOLE
Middle Name:
Last Name:MACKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 11TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-4164
Mailing Address - Country:US
Mailing Address - Phone:505-934-3767
Mailing Address - Fax:
Practice Address - Street 1:202 11TH AVE NW
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-4164
Practice Address - Country:US
Practice Address - Phone:505-934-3767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care