Provider Demographics
NPI:1316579071
Name:MAHESWARAN, COLLEEN RENEE
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:RENEE
Last Name:MAHESWARAN
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 1:1295 KERN RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48363-1936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1295 KERN RD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MI
Practice Address - Zip Code:48363-1936
Practice Address - Country:US
Practice Address - Phone:313-378-3788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7602000007176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife