Provider Demographics
NPI:1992097802
Name:MACK, ALEXIS (LPN)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
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 1:2 CAHILL ST
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-1858
Mailing Address - Country:US
Mailing Address - Phone:631-789-8525
Mailing Address - Fax:631-789-4086
Practice Address - Street 1:2 CAHILL ST
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-1858
Practice Address - Country:US
Practice Address - Phone:631-789-8525
Practice Address - Fax:631-789-4086
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293904-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse