Provider Demographics
NPI:1316594039
Name:MACK, ELIANNA GAIL EDWARDS
Entity type:Individual
Prefix:
First Name:ELIANNA
Middle Name:GAIL EDWARDS
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIANNA
Other - Middle Name:GAIL
Other - Last Name:EWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:891 BELSLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:891 BELSLY BLVD
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5055
Practice Address - Country:US
Practice Address - Phone:218-287-4338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist