Provider Demographics
NPI:1902518640
Name:MACK, SHAVONTE NICOLE (PHLEBOTOMIST, MOBILE)
Entity type:Individual
Prefix:MISS
First Name:SHAVONTE
Middle Name:NICOLE
Last Name:MACK
Suffix:
Gender:F
Credentials:PHLEBOTOMIST, MOBILE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 FORE RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-4520
Mailing Address - Country:US
Mailing Address - Phone:843-409-3638
Mailing Address - Fax:
Practice Address - Street 1:221 FORE RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-4520
Practice Address - Country:US
Practice Address - Phone:843-409-3638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9989149376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide