Healthcare Provider Details

I. General information

NPI: 1952702383
Provider Name (Legal Business Name): CHRISTINE WILLEY MACKO BSN, RN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTINE LOUISE WILLEY

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE STE 1D03
FORT STEWART GA
31314-5641
US

IV. Provider business mailing address

1061 HARMON AVE STE 1D03
FORT STEWART GA
31314-5641
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-5101
  • Fax:
Mailing address:
  • Phone: 912-435-5101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN320388L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License Number710724
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number710724
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License NumberRN242355
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number227203
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: