Provider Demographics
NPI:1679461222
Name:MACK, RACHELLE SHARON (LVN)
Entity type:Individual
Prefix:
First Name:RACHELLE
Middle Name:SHARON
Last Name:MACK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:RACHELLE
Other - Middle Name:SHARON
Other - Last Name:MACK-WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:3663 COUNTRY CLUB DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3869
Mailing Address - Country:US
Mailing Address - Phone:858-883-1902
Mailing Address - Fax:
Practice Address - Street 1:3663 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803
Practice Address - Country:US
Practice Address - Phone:562-285-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA281929164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse