Healthcare Provider Details

I. General information

NPI: 1629052154
Provider Name (Legal Business Name): MARY CAMMACK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 S 16TH ST SUITE 405
LINCOLN NE
68502-3796
US

IV. Provider business mailing address

2222 S 16TH ST SUITE 405
LINCOLN NE
68502-3796
US

V. Phone/Fax

Practice location:
  • Phone: 402-474-3704
  • Fax: 402-474-3748
Mailing address:
  • Phone: 402-474-3704
  • Fax: 402-474-3748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number110341
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: