Provider Demographics
NPI:1548552904
Name:MACK, VIRGINIA CARYL (NP)
Entity type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:CARYL
Last Name:MACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:VIRGINIA
Other - Middle Name:CARYL
Other - Last Name:OTTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:VIRGINIA C MACK
Mailing Address - Street 2:415 S. WASHINGTON AVENUE
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-2571
Mailing Address - Country:US
Mailing Address - Phone:360-621-1409
Mailing Address - Fax:848-213-0217
Practice Address - Street 1:CIRQUE MEADOW PSYCHIATRY
Practice Address - Street 2:211 WEST MYRTE STREET, SUITE 207
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-2971
Practice Address - Country:US
Practice Address - Phone:360-621-1409
Practice Address - Fax:848-213-0217
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONP990068363LP0808X
COAPN0990068-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health