MEDICARE: MADONNA ADALENE MACKIE AAS, BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	505598-1	NY

General Provider Information

NPI Number	:	1013428986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADONNA ADALENE MACKIE AAS, BC

Provider Business Mailing Address
First Line	:	3065 GRAND CONCOURSE APT 2B
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-1422
Country	:	US
Telephone Number	:	718-736-5109
Fax Number	:

Provider Business Practice Location Address
First Line	:	3065 GRAND CONCOURSE APT 2B
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-1422
Country	:	US
Telephone Number	:	718-736-5109
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2017
Last Update Date	:	10/18/2017

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