Provider Demographics
NPI:1154177913
Name:MACK, MARQUITA (LICENSED PRACTICAL N)
Entity type:Individual
Prefix:
First Name:MARQUITA
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:LICENSED PRACTICAL N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5836 N HOPE ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2412
Mailing Address - Country:US
Mailing Address - Phone:215-421-8093
Mailing Address - Fax:484-640-5994
Practice Address - Street 1:960A HARVEST DR # 100
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-1991
Practice Address - Country:US
Practice Address - Phone:215-421-8093
Practice Address - Fax:484-640-5994
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN312757164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse