Provider Demographics
NPI:1609353911
Name:MACKALL, GERTRUDE CHITI (NURSE)
Entity type:Individual
Prefix:
First Name:GERTRUDE
Middle Name:CHITI
Last Name:MACKALL
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6007 RUSSETT MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2196
Mailing Address - Country:US
Mailing Address - Phone:443-280-2625
Mailing Address - Fax:
Practice Address - Street 1:6007 RUSSETT MEADOW CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-2196
Practice Address - Country:US
Practice Address - Phone:936-756-5974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX321255164X00000X
TX980906163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse