Provider Demographics
NPI:1700171378
Name:MACK, THERESA (LPN)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:394 ELECTRIC AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14613-1004
Mailing Address - Country:US
Mailing Address - Phone:585-317-7712
Mailing Address - Fax:
Practice Address - Street 1:394 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14613-1004
Practice Address - Country:US
Practice Address - Phone:585-317-7712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-12
Last Update Date:2011-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300781164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse