Healthcare Provider Details

I. General information

NPI: 1568822252
Provider Name (Legal Business Name): LISA PASCAL MACK F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1483 TOBIAS GLADSON BLVD SUITE 209
CHARLESTON SC
29407
US

IV. Provider business mailing address

1483 TOBIAS GLADSON BLVD SUITE 209
CHARLESTON SC
29407
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-4113
  • Fax:
Mailing address:
  • Phone: 843-792-9888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number082279-23
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2310334
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number25487
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95003696
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: