Provider Demographics
NPI:1912282096
Name:MACK, MELISSA ANN (ACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:MACK
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:121 WOODCREEK CT
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-1272
Mailing Address - Country:US
Mailing Address - Phone:248-904-6816
Mailing Address - Fax:248-561-9610
Practice Address - Street 1:30805 ANN ARBOR TRL
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2482
Practice Address - Country:US
Practice Address - Phone:734-744-7084
Practice Address - Fax:734-744-7058
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704259890363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care