Provider Demographics
NPI:1023879657
Name:MAHAFFY, KAITLYN MARIE
Entity type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:MARIE
Last Name:MAHAFFY
Suffix:
Gender:
Credentials:
Other - Prefix:MS
Other - First Name:KAITLYN
Other - Middle Name:MARIE
Other - Last Name:AMEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2719 STONE ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-2844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3406
Practice Address - Country:US
Practice Address - Phone:810-662-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704360402163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse