Provider Demographics
NPI:1255731501
Name:MAHONEY, KEISHA ANTOINETTE (FNP)
Entity type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:ANTOINETTE
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:KEISHA
Other - Middle Name:
Other - Last Name:HINES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:20 STEVEN PL
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-5423
Mailing Address - Country:US
Mailing Address - Phone:516-754-0073
Mailing Address - Fax:
Practice Address - Street 1:20 STEVEN PL
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-5423
Practice Address - Country:US
Practice Address - Phone:516-754-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-23
Last Update Date:2014-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33339112363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily