Provider Demographics
NPI:1295320166
Name:MACK, TAYLOR (RN, CLC)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:RN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 HIDDEN VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-6602
Mailing Address - Country:US
Mailing Address - Phone:517-410-5494
Mailing Address - Fax:
Practice Address - Street 1:263 HIDDEN VILLAGE CT
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-6602
Practice Address - Country:US
Practice Address - Phone:517-410-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4707335337163WL0100X
OHRN.464564163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant