Provider Demographics
NPI:1104225317
Name:MAHAN, JOANN (APRN)
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:MAHAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3416 OLD GREENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5462
Mailing Address - Country:US
Mailing Address - Phone:479-242-2888
Mailing Address - Fax:479-242-2889
Practice Address - Street 1:3416 OLD GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5462
Practice Address - Country:US
Practice Address - Phone:479-242-2888
Practice Address - Fax:479-242-2889
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR43284163WE0003X
ARA004261363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency