Provider Demographics
NPI:1487068425
Name:MACK, FLORASTINE (RN)
Entity type:Individual
Prefix:MS
First Name:FLORASTINE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:FLORASTINE
Other - Middle Name:
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1101 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4802
Mailing Address - Country:US
Mailing Address - Phone:817-321-5307
Mailing Address - Fax:817-321-5338
Practice Address - Street 1:1101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4802
Practice Address - Country:US
Practice Address - Phone:817-321-5307
Practice Address - Fax:817-321-5338
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX549605163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse