Provider Demographics
NPI:1841478112
Name:MACK, KEISHA LARONE (LPN)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:LARONE
Last Name:MACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8137 EQUITANA WAY
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-9148
Mailing Address - Country:US
Mailing Address - Phone:614-575-2769
Mailing Address - Fax:
Practice Address - Street 1:8137 EQUITANA WAY
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004-9148
Practice Address - Country:US
Practice Address - Phone:614-575-2769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH128860164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse