Provider Demographics
NPI:1184274029
Name:MACK, ROCQUEL (LVN)
Entity type:Individual
Prefix:MRS
First Name:ROCQUEL
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 SHELLEY CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92880
Mailing Address - Country:US
Mailing Address - Phone:951-733-7174
Mailing Address - Fax:951-256-1517
Practice Address - Street 1:2131 SHELLEY CIRCLE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92880
Practice Address - Country:US
Practice Address - Phone:951-733-7174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN147251164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse