Provider Demographics
NPI:1528453362
Name:MAHONE, STACIA A (AGPC NP-C)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:A
Last Name:MAHONE
Suffix:
Gender:F
Credentials:AGPC NP-C
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:A
Other - Last Name:GROVE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:8081 INNOVATION PARK DR STE 900
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4867
Practice Address - Country:US
Practice Address - Phone:571-472-4100
Practice Address - Fax:571-472-4101
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172491363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health