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NPI Code Detail

MEDICARE: GENEVIEVE D. MACK CRNP

MEDICARE: GENEVIEVE D. MACK CRNP
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
1363LP0200XPediatric Nurse Practitioner216149NC

General Provider Information

NPI Number : 1447255542
Entity Type Code : Individual
Provider Name (Legal Business Name) : GENEVIEVE D. MACK CRNP
Provider Business Mailing Address
First Line : 100 GANNETT DR STE C
Second Line :
City : SOUTH PORTLAND
State : ME
Zip : 04106-5900
Country : US
Telephone Number : 207-347-2947
Fax Number : 207-874-2317
Provider Business Practice Location Address
First Line : 84 MARGINAL WAY STE 1000
Second Line :
City : PORTLAND
State : ME
Zip : 04101-2477
Country : US
Telephone Number : 207-774-4092
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/15/2005
Last Update Date : 03/04/2026

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