Provider Demographics
NPI:1215456074
Name:MAHON, CARLY M (FNP-BC)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:M
Last Name:MAHON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1147 COUNTY ROAD 193
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38828-9079
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:670 HIGHWAY 178 W STE 5
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:MS
Practice Address - Zip Code:38869-7000
Practice Address - Country:US
Practice Address - Phone:662-269-2151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902291363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily