Provider Demographics
NPI:1922399542
Name:MAHOOTY, STEPHANIE JULIET (NP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JULIET
Last Name:MAHOOTY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 W BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6041
Mailing Address - Country:US
Mailing Address - Phone:480-834-9039
Mailing Address - Fax:809-647-8024
Practice Address - Street 1:612 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6041
Practice Address - Country:US
Practice Address - Phone:480-834-9039
Practice Address - Fax:480-964-7802
Is Sole Proprietor?:No
Enumeration Date:2011-04-30
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR48437363LA2200X
NMCNP02584363LA2200X
AZAP3997363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health