Individual
MS. KAKETHIA S. MACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NURSE PRACTITIONER
Contact information
Practice address
4124 BOSENBERRY WAY, ELLENWOOD, GA 30294
(678) 463-6568
(678) 463-6568
Mailing address
4124 BOSENBERRY WAY, ELLENWOOD, GA 30294-4265
(678) 463-6568
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
RN154797
GA
Other
Enumeration date
01/30/2018
Last updated
07/02/2018
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