Provider Demographics
NPI:1386987451
Name:MAHONEY, JAMIE SUE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:SUE
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 1:12 HOGARTH AVE
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1126
Mailing Address - Country:US
Mailing Address - Phone:315-521-5633
Mailing Address - Fax:
Practice Address - Street 1:12 HOGARTH AVE
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1126
Practice Address - Country:US
Practice Address - Phone:315-521-5633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301259164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse