Provider Demographics
NPI:1619580693
Name:MACK, ERICA JAYNE (CNP)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:JAYNE
Last Name:MACK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 W MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-2907
Mailing Address - Country:US
Mailing Address - Phone:740-407-9240
Mailing Address - Fax:
Practice Address - Street 1:542 W MULBERRY ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-2907
Practice Address - Country:US
Practice Address - Phone:740-407-9240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCNP023991207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCNP023991Medicaid