Healthcare Provider Details

I. General information

NPI: 1912088055
Provider Name (Legal Business Name): MS. VICKIE ROCHELLE MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VICKIE ROCHELLE MACK LPN

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 ALVAREDO ST
JACKSON MS
39204-5317
US

IV. Provider business mailing address

811 ALVAREDO ST
JACKSON MS
39204-5317
US

V. Phone/Fax

Practice location:
  • Phone: 601-372-8941
  • Fax:
Mailing address:
  • Phone: 601-372-8941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberP122165
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: