Provider Demographics
NPI:1124635875
Name:MACE, SIERRA BROOKE (RN)
Entity type:Individual
Prefix:
First Name:SIERRA
Middle Name:BROOKE
Last Name:MACE
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 1:601 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-1420
Mailing Address - Country:US
Mailing Address - Phone:304-455-1990
Mailing Address - Fax:304-455-5536
Practice Address - Street 1:601 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-1420
Practice Address - Country:US
Practice Address - Phone:304-455-1990
Practice Address - Fax:304-455-5536
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV100620163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0000OtherN/A