Provider Demographics
NPI:1083770945
Name:HANNAFIOUS, MARILYN J (WHCNP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:J
Last Name:HANNAFIOUS
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9202 ELAM RD
Practice Address - Street 2:SOUTHEAST DALLAS WOMEN'S HEALTH CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-4151
Practice Address - Country:US
Practice Address - Phone:214-266-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX585550363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140078016Medicaid
TX140078026Medicaid
TX8Y2909OtherBLUE CROSS BLUE SHIELD
TX140078021Medicaid
TX140078023Medicaid
TX140078019Medicaid
TX140078022Medicaid
TX140078027Medicaid
TX140078020Medicaid
TX140078024Medicaid
TX140078025Medicaid
TX140078028Medicaid