Provider Demographics
NPI:1700398690
Name:MACK, FELICIA M (PCA)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:FELICIA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PCA
Mailing Address - Street 1:307 KENDRICK ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-2196
Mailing Address - Country:US
Mailing Address - Phone:678-758-2092
Mailing Address - Fax:
Practice Address - Street 1:307 KENDRICK ESTATES DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-2196
Practice Address - Country:US
Practice Address - Phone:678-758-2092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000000000OtherNOT APPLICABLE