Provider Demographics
NPI:1962023598
Name:MACK, MARY (DNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10707 PLEASANT VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-9154
Mailing Address - Country:US
Mailing Address - Phone:661-204-2455
Mailing Address - Fax:
Practice Address - Street 1:3805 SAN DIMAS ST STE B
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-5725
Practice Address - Country:US
Practice Address - Phone:661-326-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014527363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95014527OtherNP LICENSE
CAMM587621OtherDEA