Healthcare Provider Details

I. General information

NPI: 1558028027
Provider Name (Legal Business Name): EBAN JAMES MACKEY II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 03/22/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 BELLE CHASE WAY
LANSING MI
48911-4252
US

IV. Provider business mailing address

544 EAST DR
MARSHALL MI
49068-1363
US

V. Phone/Fax

Practice location:
  • Phone: 517-882-3732
  • Fax:
Mailing address:
  • Phone: 269-274-2963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704280061
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: