Provider Demographics
NPI:1659517506
Name:MBAH, PORTIA
Entity Type:Individual
Prefix:MRS
First Name:PORTIA
Middle Name:
Last Name:MBAH
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 1:4108 MULBERRY DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-1058
Mailing Address - Country:US
Mailing Address - Phone:469-999-7368
Mailing Address - Fax:
Practice Address - Street 1:4108 MULBERRY DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-1058
Practice Address - Country:US
Practice Address - Phone:469-767-1870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-24
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX1005797164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program