Healthcare Provider Details

I. General information

NPI: 1215072715
Provider Name (Legal Business Name): REBA JEAN MAHAFFEY RN MS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S MCKINLEY AVE
RENSSELAER IN
47978-2949
US

IV. Provider business mailing address

123 S MCKINLEY AVE
RENSSELAER IN
47978-2949
US

V. Phone/Fax

Practice location:
  • Phone: 219-866-7222
  • Fax: 219-866-7001
Mailing address:
  • Phone: 219-866-7222
  • Fax: 219-866-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71001207A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: