Healthcare Provider Details

I. General information

NPI: 1699191163
Provider Name (Legal Business Name): MICHELLE ANGELINA MACK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2014
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2645 MERIDIAN PKWY STE 323
DURHAM NC
27713-4232
US

IV. Provider business mailing address

PO BOX 746724
ATLANTA GA
30374-6724
US

V. Phone/Fax

Practice location:
  • Phone: 984-227-8902
  • Fax: 844-813-6747
Mailing address:
  • Phone: 312-733-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5006858
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0314142
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: