Provider Demographics
NPI:1790203370
Name:MACK, KAITLIN MARIE (CNP)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:MACK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3600 S OLD 3C HWY
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:OH
Mailing Address - Zip Code:43021-9518
Mailing Address - Country:US
Mailing Address - Phone:440-864-5120
Mailing Address - Fax:
Practice Address - Street 1:800 MCCONNELL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3463
Practice Address - Country:US
Practice Address - Phone:614-566-5019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.021460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily