Provider Demographics
NPI:1215767736
Name:MACKINS, JAVONDA ENITRA
Entity type:Individual
Prefix:
First Name:JAVONDA
Middle Name:ENITRA
Last Name:MACKINS
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 1:1147 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-3810
Mailing Address - Country:US
Mailing Address - Phone:732-215-8727
Mailing Address - Fax:
Practice Address - Street 1:620 MADISON ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2319
Practice Address - Country:US
Practice Address - Phone:315-426-3985
Practice Address - Fax:315-426-3605
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341331164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty