Healthcare Provider Details

I. General information

NPI: 1881309045
Provider Name (Legal Business Name): PAMELA ANN MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2023
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1183 E FOOTHILL BLVD STE 135
UPLAND CA
91786-4082
US

IV. Provider business mailing address

285 N KENNETH PL
CHANDLER AZ
85226-2944
US

V. Phone/Fax

Practice location:
  • Phone: 909-931-1368
  • Fax:
Mailing address:
  • Phone: 480-383-3198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95033833
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: