Provider Demographics
NPI:1568254464
Name:MACKE, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MACKE
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 1:710 WASHINGTON ST APT 217
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-2835
Mailing Address - Country:US
Mailing Address - Phone:502-548-2041
Mailing Address - Fax:
Practice Address - Street 1:59 CAROTHERS RD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41071-2415
Practice Address - Country:US
Practice Address - Phone:859-491-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY2431DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program