Provider Demographics
NPI:1174571186
Name:MAHONEY, CYNTHIA MARIE (FNP)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIE
Last Name:MAHONEY
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:PO BOX 2552
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97528-0213
Mailing Address - Country:US
Mailing Address - Phone:541-244-1261
Mailing Address - Fax:541-787-8130
Practice Address - Street 1:181 NW BUNNELL AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-6012
Practice Address - Country:US
Practice Address - Phone:541-474-9400
Practice Address - Fax:541-474-2232
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200250078NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100252Medicaid
OR200250078NPOtherSTATE LICENSE#
OR200250078NPOtherSTATE LICENSE#