Provider Demographics
NPI:1609612605
Name:MACK, GARDNER (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:GARDNER
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 HAVERHILL DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-3030
Mailing Address - Country:US
Mailing Address - Phone:832-373-7311
Mailing Address - Fax:
Practice Address - Street 1:333 WEST LOOP N STE 250
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-1751
Practice Address - Country:US
Practice Address - Phone:713-690-1991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1168410363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily