Healthcare Provider Details

I. General information

NPI: 1881573855
Provider Name (Legal Business Name): RUDI MARSHAE MACK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3429 MELROSE RD
FAYETTEVILLE NC
28304-1608
US

IV. Provider business mailing address

3442 BECKFORD LN
FAYETTEVILLE NC
28304-2905
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-3720
  • Fax:
Mailing address:
  • Phone: 910-339-0168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number333688
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: