1962179614 NPI number — SARAH ASHLEY MAHONEY DNP, RN, PNP-PC

Table of content: SARAH ASHLEY MAHONEY DNP, RN, PNP-PC (NPI 1962179614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962179614 NPI number — SARAH ASHLEY MAHONEY DNP, RN, PNP-PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHONEY
Provider First Name:
SARAH
Provider Middle Name:
ASHLEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DNP, RN, PNP-PC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WAGNER
Provider Other First Name:
SARAH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962179614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5608 ADELAIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43613-2008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-320-0688
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3901 BEAUBIEN STREET
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-966-8341
Provider Business Practice Location Address Fax Number:
313-966-6121
Provider Enumeration Date:
08/30/2021

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: 363LP0200X , with the licence number:  202018563 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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