Provider Demographics
NPI:1578891792
Name:MACKAVICH, SOUNDRA D (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:SOUNDRA
Middle Name:D
Last Name:MACKAVICH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 GRIXDALE LN
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-3430
Mailing Address - Country:US
Mailing Address - Phone:248-681-3622
Mailing Address - Fax:
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-858-6591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-29
Last Update Date:2009-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2488088363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily