Provider Demographics
NPI:1992092183
Name:MACK, TERESA CHANELLE (LPN)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:CHANELLE
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 1:8605 N GRANVILLE RD
Mailing Address - Street 2:APT.6
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-2368
Mailing Address - Country:US
Mailing Address - Phone:414-366-0912
Mailing Address - Fax:
Practice Address - Street 1:8605 N GRANVILLE RD
Practice Address - Street 2:APT.6
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-2368
Practice Address - Country:US
Practice Address - Phone:414-366-0912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI309311-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse