Provider Demographics
NPI:1841794047
Name:MACK, DARLA JEAN
Entity type:Individual
Prefix:MRS
First Name:DARLA
Middle Name:JEAN
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 1:7312 BUFORD DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75241-4505
Mailing Address - Country:US
Mailing Address - Phone:469-616-9164
Mailing Address - Fax:
Practice Address - Street 1:7312 BUFORD DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75241-4505
Practice Address - Country:US
Practice Address - Phone:469-616-9164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305341164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse