Provider Demographics
NPI:1023763455
Name:MACK, MICHELLE M (DNP, CRNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:DNP, CRNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP, CRNP
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1800 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-2369
Practice Address - Country:US
Practice Address - Phone:570-969-0161
Practice Address - Fax:570-969-0163
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP024034363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner