Provider Demographics
NPI:1881067817
Name:MACK, DANA LEE
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:LEE
Last Name:MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 MAIN STREET N
Mailing Address - Street 2:
Mailing Address - City:RENVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56284-0606
Mailing Address - Country:US
Mailing Address - Phone:320-329-8395
Mailing Address - Fax:320-329-8397
Practice Address - Street 1:420 MAIN STREET N
Practice Address - Street 2:
Practice Address - City:RENVILLE
Practice Address - State:MN
Practice Address - Zip Code:56284-0606
Practice Address - Country:US
Practice Address - Phone:320-329-8395
Practice Address - Fax:320-329-8397
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP4218363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily