Basic Information
| Provider Information | |||||||||
| NPI: | 1386216935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | LENAY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1314 VALLEY VIEW RD | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303384823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136419942 | ||||||||
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| Practice Location | |||||||||
| Address1: | 677 CHURCH ST NE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707940477 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2021 | ||||||||
| LastUpdateDate: | 10/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN258358 | GA | N | Nursing Service Providers | Registered Nurse | 367500000X | RN258368 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.