Provider Demographics
NPI:1942018775
Name:MACK, CRYSTAL EMILY (PMHNP)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:EMILY
Last Name:MACK
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19099 E WALNUT CT
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-2436
Mailing Address - Country:US
Mailing Address - Phone:480-278-6650
Mailing Address - Fax:
Practice Address - Street 1:19099 E WALNUT CT
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-2436
Practice Address - Country:US
Practice Address - Phone:480-278-6650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-26
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ317705363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health