Provider Demographics
NPI:1134484926
Name:MAHAN, MONTIQUE STEPHON
Entity Type:Individual
Prefix:
First Name:MONTIQUE
Middle Name:STEPHON
Last Name:MAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 FAIRMONT ST NW APT 312
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-6917
Mailing Address - Country:US
Mailing Address - Phone:202-710-5556
Mailing Address - Fax:
Practice Address - Street 1:1818 NEW YORK AVE NE STE 228
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-1851
Practice Address - Country:US
Practice Address - Phone:202-710-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide