Provider Demographics
NPI:1912088055
Name:MACK, VICKIE ROCHELLE
Entity type:Individual
Prefix:MS
First Name:VICKIE
Middle Name:ROCHELLE
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:VICKIE
Other - Middle Name:ROCHELLE
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:811 ALVAREDO ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-5317
Mailing Address - Country:US
Mailing Address - Phone:601-372-8941
Mailing Address - Fax:
Practice Address - Street 1:811 ALVAREDO ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-5317
Practice Address - Country:US
Practice Address - Phone:601-372-8941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP122165164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770172Medicaid