Healthcare Provider Details

I. General information

NPI: 1962023598
Provider Name (Legal Business Name): MARY MACK DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 03/07/2023
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 SAN DIMAS ST STE B
BAKERSFIELD CA
93301-5725
US

IV. Provider business mailing address

10707 PLEASANT VALLEY DR
BAKERSFIELD CA
93311-9154
US

V. Phone/Fax

Practice location:
  • Phone: 661-326-9999
  • Fax:
Mailing address:
  • Phone: 661-204-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95014527
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: