Basic Information
| Provider Information | |||||||||
| NPI: | 1174565428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHONEY | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ROWAN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNP, MSN, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 MARKET ST | ||||||||
| Address2: | LM 500 WEST TOWER | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191022100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159852595 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 N 9TH ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191222024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157656690 | ||||||||
| FaxNumber: | 2157656694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 07/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | UP001097C | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1590259 | 01 | PA | BLUE CROSS | OTHER | 7934856 | 01 | PA | AETNA | OTHER | 30027025 | 01 | PA | KEYSTONE MERCY HEALTH PLAN | OTHER | 16621 | 01 | PA | BRAVO | OTHER | 2268269000 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER | 0016148450001 | 05 | PA | MEDICAID |