Healthcare Provider Details

I. General information

NPI: 1609353911
Provider Name (Legal Business Name): GERTRUDE CHITI MACKALL NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6007 RUSSETT MEADOW CT
RICHMOND TX
77407-2196
US

IV. Provider business mailing address

6007 RUSSETT MEADOW CT
RICHMOND TX
77407-2196
US

V. Phone/Fax

Practice location:
  • Phone: 936-756-5974
  • Fax:
Mailing address:
  • Phone: 443-280-2625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number321255
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number980906
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: