Healthcare Provider Details

I. General information

NPI: 1124423777
Provider Name (Legal Business Name): CETESSA MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W MORRIS BLVD SUITE 130
MORRISTOWN TN
37813-2283
US

IV. Provider business mailing address

420 W MORRIS BLVD STE 130
MORRISTOWN TN
37813-2255
US

V. Phone/Fax

Practice location:
  • Phone: 423-581-3939
  • Fax: 423-318-2200
Mailing address:
  • Phone: 423-581-3939
  • Fax: 423-318-2200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18998
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: