Provider Demographics
NPI:1710348008
Name:MACK, LAKISHA
Entity Type:Individual
Prefix:
First Name:LAKISHA
Middle Name:
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 1:6397 THORNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-5158
Mailing Address - Country:US
Mailing Address - Phone:313-850-7008
Mailing Address - Fax:
Practice Address - Street 1:6397 THORNWOOD DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-5158
Practice Address - Country:US
Practice Address - Phone:313-850-7008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704310121163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse