Healthcare Provider Details

I. General information

NPI: 1396205753
Provider Name (Legal Business Name): MACY MANDELINE DEEDS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACY MANDLINE STORK APRN

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2717 S 108TH ST STE 200
OMAHA NE
68144-4811
US

IV. Provider business mailing address

1001 S OHIO ST
SALINA KS
67401-5364
US

V. Phone/Fax

Practice location:
  • Phone: 402-933-8201
  • Fax: 402-933-8301
Mailing address:
  • Phone: 785-827-6453
  • Fax: 785-823-1255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-78509-051
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number112734
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: