Provider Demographics
NPI:1417286436
Name:MAHAN, KELLEY A (ANP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:A
Last Name:MAHAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CHERRY ST
Mailing Address - Street 2:SUITE 11511
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1321
Mailing Address - Country:US
Mailing Address - Phone:215-255-7822
Mailing Address - Fax:
Practice Address - Street 1:1625 CHESTNUT ST
Practice Address - Street 2:THE SHOPS AT LIBERTY PLACE - SPACE 172
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-4206
Practice Address - Country:US
Practice Address - Phone:215-399-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN542909163W00000X
PASP010687363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse