Provider Demographics
NPI:1134435092
Name:MACK, SHELLEY DIANE
Entity type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:DIANE
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 1:1514 BALDWIN LAKES DR
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5887
Mailing Address - Country:US
Mailing Address - Phone:706-854-0555
Mailing Address - Fax:706-651-9677
Practice Address - Street 1:1514 BALDWIN LAKES DR
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-5887
Practice Address - Country:US
Practice Address - Phone:706-854-0555
Practice Address - Fax:706-651-9677
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-29
Last Update Date:2010-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
No376J00000XNursing Service Related ProvidersHomemaker