Provider Demographics
NPI:1659946994
Name:MACK, ANITA L
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:L
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 1:10851 ROAD 230
Mailing Address - Street 2:
Mailing Address - City:CECIL
Mailing Address - State:OH
Mailing Address - Zip Code:45821-9307
Mailing Address - Country:US
Mailing Address - Phone:419-399-3444
Mailing Address - Fax:419-782-3618
Practice Address - Street 1:10851 ROAD 230
Practice Address - Street 2:
Practice Address - City:CECIL
Practice Address - State:OH
Practice Address - Zip Code:45821-9307
Practice Address - Country:US
Practice Address - Phone:419-399-3444
Practice Address - Fax:419-782-3618
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0028819363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily