Provider Demographics
NPI:1386245504
Name:MACK, PATRICIA ROSE
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:ROSE
Last Name:MACK
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 1:8259 STATE ROUTE 88
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-9158
Mailing Address - Country:US
Mailing Address - Phone:330-296-0322
Mailing Address - Fax:330-296-0322
Practice Address - Street 1:8259 STATE ROUTE 88
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-9158
Practice Address - Country:US
Practice Address - Phone:330-296-0322
Practice Address - Fax:330-296-0322
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2084355Medicaid