Provider Demographics
NPI:1104363720
Name:MAC, CHRISTINE (NP)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:MAC
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12020 HALLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-1518
Mailing Address - Country:US
Mailing Address - Phone:626-203-9157
Mailing Address - Fax:
Practice Address - Street 1:11865 FIRESTONE BLVD
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2902
Practice Address - Country:US
Practice Address - Phone:562-806-1214
Practice Address - Fax:562-806-1218
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95004943363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95004943OtherLICENCE