Provider Demographics
NPI:1194367383
Name:MACK, CHARLOTTE (APRN)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551308
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1308
Mailing Address - Country:US
Mailing Address - Phone:904-622-9040
Mailing Address - Fax:904-309-5691
Practice Address - Street 1:1681 EAGLE HARBOR PKWY STE B
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4819
Practice Address - Country:US
Practice Address - Phone:904-644-0092
Practice Address - Fax:904-644-0099
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002748363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily