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General NPI Number Information
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NPI Number | 1396813960
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Entity Type | Individual
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Provider Name | KELLY LEIGH MACK PA-C
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Gender | Female
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Dates
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Enumeration Date | 12/01/2006
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Last Update Date | 08/13/2019
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Provider Practice Location Address
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Address Line | 995 N. PRINCE FREDERICK BLVD SUITE 204
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City | PRINCE FREDERICK
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State | MD
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Zip | 20678
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Country | US
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Telephone | 410-535-5855
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Fax | 410-535-6574
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Provider Business Mailing Address
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Address Line | 4505 KINGWOOD DR STE 185
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City | KINGWOOD
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State | TX
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Zip | 77345-2618
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Country | US
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Telephone | 281-747-5533
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Fax | 281-747-5534
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA18061
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA07662
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License Number State | TX
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