Provider Demographics
NPI:1447255542
Name:MACK, GENEVIEVE D (CRNP)
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:D
Last Name:MACK
Suffix:
Gender:
Credentials:CRNP
Other - Prefix:
Other - First Name:GENEVIEVE
Other - Middle Name:D
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY STE 1000
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2477
Practice Address - Country:US
Practice Address - Phone:207-774-4092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC216149363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics