Provider Demographics
NPI:1801401922
Name:MCMAHAN, MADRINA
Entity Type:Individual
Prefix:
First Name:MADRINA
Middle Name:
Last Name:MCMAHAN
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:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:CADDO MILLS
Mailing Address - State:TX
Mailing Address - Zip Code:75135-0552
Mailing Address - Country:US
Mailing Address - Phone:903-413-3033
Mailing Address - Fax:
Practice Address - Street 1:4215 JOE RAMSEY BLVD E
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-7852
Practice Address - Country:US
Practice Address - Phone:903-408-5633
Practice Address - Fax:903-408-1519
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX616375163W00000X
TXL-150985163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty