Provider Demographics
NPI:1952702383
Name:WILLEY MACKO, CHRISTINE (BSN, RN-BC)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:WILLEY MACKO
Suffix:
Gender:F
Credentials:BSN, RN-BC
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:LOUISE
Other - Last Name:WILLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE STE 1D03
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-5101
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE STE 1D03
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-5101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN320388L163W00000X
TX710724163WG0100X, 163WP2201X
GARN242355163WX0106X
NC227203261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0106XNursing Service ProvidersRegistered NurseOccupational Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WG0100XNursing Service ProvidersRegistered NurseGastroenterology
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical