Provider Demographics
NPI:1316070287
Name:CENTENO, MAE MAGDALEN (MS RN,CCRN,CCNS,ACNS)
Entity type:Individual
Prefix:
First Name:MAE
Middle Name:MAGDALEN
Last Name:CENTENO
Suffix:
Gender:F
Credentials:MS RN,CCRN,CCNS,ACNS
Other - Prefix:
Other - First Name:MAE
Other - Middle Name:MAGDALEN
Other - Last Name:CENTENO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS RN,CCRN,CCNS,ACNS
Mailing Address - Street 1:6800 AMETHYST LN
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-1936
Mailing Address - Country:US
Mailing Address - Phone:972-517-6145
Mailing Address - Fax:
Practice Address - Street 1:621 N HALL ST
Practice Address - Street 2:SUITE 120
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75226-1339
Practice Address - Country:US
Practice Address - Phone:214-820-1740
Practice Address - Fax:214-820-1638
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX552502364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX450021Medicare PIN