Basic Information
| Provider Information | |||||||||
| NPI: | 1174928287 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | HUONG | ||||||||
| MiddleName: | X | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LE | ||||||||
| OtherFirstName: | HUONG | ||||||||
| OtherMiddleName: | X | ||||||||
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| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 67250 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024136706 | ||||||||
| FaxNumber: | 8889650959 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 PINE LAKE RD | ||||||||
| Address2: | STE 5 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685165489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023288833 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2014 | ||||||||
| LastUpdateDate: | 08/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 111737 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363L00000X | 111737 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 47075636998 | 05 | NE | MEDICAID | 10025734000 | 05 | NE | MEDICAID | 10026038300 | 05 | NE | MEDICAID | 47075636930 | 05 | NE | MEDICAID |