Provider Demographics
NPI:1164825261
Name:MAHANNAH-JOHN, DIANA
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:
Last Name:MAHANNAH-JOHN
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 1:7428 PARK PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77087-4442
Mailing Address - Country:US
Mailing Address - Phone:713-643-5858
Mailing Address - Fax:713-643-2967
Practice Address - Street 1:7428 PARK PLACE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77087-4442
Practice Address - Country:US
Practice Address - Phone:713-643-5858
Practice Address - Fax:713-643-2967
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76-1067155261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone