Provider Demographics
NPI:1023124294
Name:MAHONY, KATHLEEN BERNICE (FNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BERNICE
Last Name:MAHONY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 E ALESSANDRO BLVD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6071
Mailing Address - Country:US
Mailing Address - Phone:951-780-1835
Mailing Address - Fax:951-780-2936
Practice Address - Street 1:491 E ALESSANDRO BLVD
Practice Address - Street 2:#9803
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-6071
Practice Address - Country:US
Practice Address - Phone:951-780-1835
Practice Address - Fax:951-780-2936
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN300198163W00000X
CA11410363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP19557Medicare UPIN
CABJ104ZMedicare PIN
CABJ064ZMedicare PIN
CABJ104YMedicare PIN