Provider Demographics
NPI:1013428986
Name:MACKIE, MADONNA ADALENE (AAS, BC)
Entity Type:Individual
Prefix:
First Name:MADONNA
Middle Name:ADALENE
Last Name:MACKIE
Suffix:
Gender:F
Credentials:AAS, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3065 GRAND CONCOURSE APT 2B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-1422
Mailing Address - Country:US
Mailing Address - Phone:718-736-5109
Mailing Address - Fax:
Practice Address - Street 1:3065 GRAND CONCOURSE APT 2B
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-1422
Practice Address - Country:US
Practice Address - Phone:718-736-5109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY505598-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse