Provider Demographics
NPI:1891740981
Name:PACK-MABIEN, ARDIE VANESSA (CRNP)
Entity Type:Individual
Prefix:
First Name:ARDIE
Middle Name:VANESSA
Last Name:PACK-MABIEN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-410-5437
Mailing Address - Fax:251-434-3852
Practice Address - Street 1:1601 CENTER ST
Practice Address - Street 2:STE 1S
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1512
Practice Address - Country:US
Practice Address - Phone:251-410-5437
Practice Address - Fax:251-434-3852
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-050071363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124955Medicaid
FL304248100Medicaid
AL51505390OtherBLUE CROSS
AL891003660Medicaid
FL304248100Medicaid
AL51505390OtherBLUE CROSS
AL051505390Medicare ID - Type Unspecified