1780850966 NPI number — MS. KATHLEEN ANN MAHL APRN

Table of content: MS. KATHLEEN ANN MAHL APRN (NPI 1780850966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780850966 NPI number — MS. KATHLEEN ANN MAHL APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHL
Provider First Name:
KATHLEEN
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOOTH
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
MAHL
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780850966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1375 CORPORATE SQUARE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SLIDELL
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70458-3147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-726-2655
Provider Business Mailing Address Fax Number:
985-643-9808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
56 STARBRUSH CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-7208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-871-0095
Provider Business Practice Location Address Fax Number:
985-871-0529
Provider Enumeration Date:
05/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  RN076670 AP05454 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1348228 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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