Provider Demographics
NPI:1386329514
Name:MAHANEY, TIMOTHY J (APRN)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:MAHANEY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3665 SCHOOLHOUSE RD W UNIT 403
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-8208
Mailing Address - Country:US
Mailing Address - Phone:860-736-7036
Mailing Address - Fax:
Practice Address - Street 1:3665 SCHOOLHOUSE RD W UNIT 403
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-8208
Practice Address - Country:US
Practice Address - Phone:860-736-7036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11026961363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health