Provider Demographics
NPI:1710115654
Name:MACK, ALISHA NOEL (MSN)
Entity Type:Individual
Prefix:MRS
First Name:ALISHA
Middle Name:NOEL
Last Name:MACK
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 S MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-3102
Mailing Address - Country:US
Mailing Address - Phone:574-283-5572
Mailing Address - Fax:
Practice Address - Street 1:813 S MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-3102
Practice Address - Country:US
Practice Address - Phone:574-283-5572
Practice Address - Fax:574-283-5571
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28169564A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200962090Medicaid
IN178420LLMedicare Oscar/Certification