Provider Demographics
NPI:1851601348
Name:MACK, DOROTHY ANN
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:ANN
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 1:463142 STATE ROAD 200
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-5554
Mailing Address - Country:US
Mailing Address - Phone:904-225-8280
Mailing Address - Fax:904-225-8835
Practice Address - Street 1:463142 STATE ROAD 200
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-5554
Practice Address - Country:US
Practice Address - Phone:904-225-8280
Practice Address - Fax:904-225-8835
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator