Provider Demographics
NPI:1457038911
Name:MAHAN, RENEE NICOLE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:NICOLE
Last Name:MAHAN
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 1:1050 N HWY 360 APT H3093
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-2555
Mailing Address - Country:US
Mailing Address - Phone:623-254-9422
Mailing Address - Fax:
Practice Address - Street 1:210 W 10TH ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4523
Practice Address - Country:US
Practice Address - Phone:214-702-9225
Practice Address - Fax:888-516-1064
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty