Provider Demographics
NPI:1194429159
Name:MAHONEY, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4669 DEWBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-7842
Mailing Address - Country:US
Mailing Address - Phone:330-524-5503
Mailing Address - Fax:
Practice Address - Street 1:4669 DEWBERRY CIR
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-7842
Practice Address - Country:US
Practice Address - Phone:330-524-5503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty