Basic Information
Provider Information | |||||||||
NPI: | 1124436118 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAHAFFEY | ||||||||
FirstName: | PAMELA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILLE | ||||||||
OtherFirstName: | PAMELA | ||||||||
OtherMiddleName: | SUE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | N.P. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3200 E RACINE ST | ||||||||
Address2: |   | ||||||||
City: | JANESVILLE | ||||||||
State: | WI | ||||||||
PostalCode: | 535462343 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083718000 | ||||||||
FaxNumber: | 6083718939 | ||||||||
Practice Location | |||||||||
Address1: | 3200 E RACINE ST | ||||||||
Address2: |   | ||||||||
City: | JANESVILLE | ||||||||
State: | WI | ||||||||
PostalCode: | 535462343 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083718000 | ||||||||
FaxNumber: | 6083718939 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2014 | ||||||||
LastUpdateDate: | 08/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5944-33 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 163W00000X | 143303-30 | WI | N |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 1124436118 | 05 | WI |   | MEDICAID |