Healthcare Provider Details

I. General information

NPI: 1578913992
Provider Name (Legal Business Name): KERI MACK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7451 GLADIOLUS DR
FORT MYERS FL
33908
US

IV. Provider business mailing address

2160 COLONIAL BLVD
FORT MYERS FL
33907-1410
US

V. Phone/Fax

Practice location:
  • Phone: 239-689-8800
  • Fax: 239-790-5471
Mailing address:
  • Phone: 239-931-7342
  • Fax: 239-931-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9109378
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: