Provider Demographics
NPI:1831490481
Name:MACK, KRISTEN ELIZABETH (RN)
Entity Type:Individual
Prefix:MISS
First Name:KRISTEN
Middle Name:ELIZABETH
Last Name:MACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40622 119TH ST
Mailing Address - Street 2:
Mailing Address - City:GENOA CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53128
Mailing Address - Country:US
Mailing Address - Phone:847-445-6942
Mailing Address - Fax:
Practice Address - Street 1:40622 119TH ST
Practice Address - Street 2:
Practice Address - City:GENOA CITY
Practice Address - State:WI
Practice Address - Zip Code:53128-2501
Practice Address - Country:US
Practice Address - Phone:847-445-6942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-13
Last Update Date:2010-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI171602-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse