MS. KAKETHIA S. MACK (NPI# 1346748837) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1346748837 |
| Entity Type | Individual |
| Full Name | MS. KAKETHIA S. MACK |
| Credential | NURSE PRACTITIONER |
| Practice Address |
4124 Bosenberry Way Ellenwood GA 30294 |
| Mailing Address |
4124 Bosenberry Way Ellenwood GA 30294-4265 |
| Practice Telephone | 6784636568 |
| Practice Fax Number | 6784636568 |
| Mailing Telephone | 6784636568 |
| Enumeration Date | 2018-01-30 |
| Last Update Date | 2018-07-02 |
| Gender Code | F |
| Is Sole Proprietor | Y |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 363LF0000X |
Nurse Practitioner Specialization: Family |
RN154797 | GA | Physician Assistants & Advanced Practice Nursing Providers |
| Street Address |
4124 BOSENBERRY WAY |
| City | ELLENWOOD |
| State | GA |
| Zip Code | 30294 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1770124323 | Lula Varist Gholson | Counselor | Christian Counselor Ma Lou Gholson, 549 Lamar Drive, Forest Park, GA 30294 | 2019-10-04 |
| 1609428176 | Tykechia Todd | Ambulance | 3644 Caseys Cove, Ellenwood, GA 30294 | 2019-07-15 |
| 1891285243 | Ayana Aqila Thornton | Nurse Practitioner | 5654 Hosea Court, Ellenwood, GA 30294 | 2018-05-11 |
| 1851819312 | Tatiana Marcus | Prosthetist | 3895 Busby Mill Ct., Ellenwood, GA 30294 | 2017-09-05 |
| 1962944991 | Fairview Urgent Care, LLC | Clinic/Center | 4475 West Village Pkwy, Ellenwood, GA 30294 | 2016-11-08 |
| 1982006169 | Kristal Cure | Licensed Practical Nurse | 4057 Madiosn Court, Ellenwood, GA 30294 | 2014-09-19 |
| 1801233515 | 1st Class Learning and Performing Arts | Local Education Agency (LEA) | 5474 Platte Dr, Ellenwood, GA 30294 | 2013-06-04 |
| 1235480138 | Life Wellness Group of Atlanta | Home Delivered Meals | 145 Wilhemina Drive, Ellenwood, GA 30294 | 2012-10-02 |
| 1346548450 | William K Holley IIi | Counselor | 2732 Holly Berry Dr, Ellenwood, GA 30294 | 2011-03-14 |
| 1174840268 | Kirsten D Person-ramey | Counselor | 5970 Mt Zion Blvd, Ellenwood, GA 30294 | 2010-04-28 |
| Find all providers in zip 30294 | ||||
| Taxonomy Code | 363LF0000X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Nurse Practitioner |
| Specialization | Family |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1265059299 | Ngassa Nchapada Menga Faith | Nurse Practitioner | 2568 Brittany Park Cv, Ellenwood, GA 30294-6288 | 2020-06-25 |
| 1477190189 | Maria Montrice Ford | Nurse Practitioner | 210 Blue Ridge Ct, Ellenwood, GA 30294-2972 | 2019-12-02 |
| 1407318678 | Brandi Melissa Pinckney | Nurse Practitioner | 117 Kalsum Trl, Ellenwood, GA 30294-3314 | 2019-04-04 |
| 1194235515 | Lisa Michele Delancy | Nurse Practitioner | 140 Huntcliff Trl, Ellenwood, GA 30294-2596 | 2017-10-11 |
| 1346797065 | Trevino C Simmons | Nurse Practitioner | 256 Essex Pl, Ellenwood, GA 30294-4106 | 2016-09-10 |
| 1710386313 | Siameco Curtis | Nurse Practitioner | 4335 Ivy Run, Ellenwood, GA 30294-6521 | 2014-08-19 |
| 1992065718 | Kathleen C Haynes | Nurse Practitioner | 4539 Warren Mill Trl, Ellenwood, GA 30294-2051 | 2012-05-26 |
| 1336304682 | Terrilyn D Lemons | Nurse Practitioner | 4018 Park Place Cir, Ellenwood, GA 30294-1500 | 2008-07-25 |
| 1437664463 | Claudea Antonette Lewis-comrie | Nurse Practitioner | 211 Fairview Rd, Ellenwood, GA 30294-2721 | 2017-12-13 |
| 1285169185 | Rose Senge Kombe | Nurse Practitioner | 211 Fairview Rd, Ellenwood, GA 30294-2721 | 2017-04-28 |
| Find all providers in ELLENWOOD | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.