Provider Demographics
NPI:1154616050
Name:CHAN, MIMI (RD, LD, CDE)
Entity type:Individual
Prefix:MRS
First Name:MIMI
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 S MASON RD STE 118
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-2437
Mailing Address - Country:US
Mailing Address - Phone:832-916-2698
Mailing Address - Fax:
Practice Address - Street 1:515 S FRY RD STE A
Practice Address - Street 2:SUITE #165
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-9100
Practice Address - Country:US
Practice Address - Phone:832-916-2698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NY007477-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9050926OtherAETNA
6236760OtherCIGNA
NY9050926OtherAETNA