Healthcare Provider Details

I. General information

NPI: 1649180522
Provider Name (Legal Business Name): SHAQUILL MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2306 LARGUIER LN
PORT ALLEN LA
70767-3201
US

IV. Provider business mailing address

2306 LARGUIER LN
PORT ALLEN LA
70767-3201
US

V. Phone/Fax

Practice location:
  • Phone: 225-262-0409
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: