Provider Demographics
NPI:1568729515
Name:MACK, CYNTHIA ANN
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:MACK
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 1:11 BATTERY BLVD
Mailing Address - Street 2:
Mailing Address - City:MECHANICVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12118-3364
Mailing Address - Country:US
Mailing Address - Phone:518-664-1856
Mailing Address - Fax:
Practice Address - Street 1:11 BATTERY BLVD
Practice Address - Street 2:
Practice Address - City:MECHANICVILLE
Practice Address - State:NY
Practice Address - Zip Code:12118-3364
Practice Address - Country:US
Practice Address - Phone:518-664-1856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist