Healthcare Provider Details

I. General information

NPI: 1255235776
Provider Name (Legal Business Name): MACK REGISTERED PROFESSIONAL NURSING SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 E POINTE DR
ITHACA NY
14850-1173
US

IV. Provider business mailing address

1307 E POINTE DR
ITHACA NY
14850-1173
US

V. Phone/Fax

Practice location:
  • Phone: 607-434-9286
  • Fax:
Mailing address:
  • Phone: 607-434-9286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KEIOSHA SHIREE MACK
Title or Position: MANAGING MEMBER
Credential: RN
Phone: 607-434-9286