Provider Demographics
NPI:1518098789
Name:MAHAFFEY, TAMERA LYN (NP)
Entity Type:Individual
Prefix:
First Name:TAMERA
Middle Name:LYN
Last Name:MAHAFFEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 MICHIGAN AVE W
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MN
Mailing Address - Zip Code:56484-2276
Mailing Address - Country:US
Mailing Address - Phone:218-547-7700
Mailing Address - Fax:
Practice Address - Street 1:614 MICHIGAN AVE W
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MN
Practice Address - Zip Code:56484-2276
Practice Address - Country:US
Practice Address - Phone:218-547-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR079624-6363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN374R6MAOtherBCBS
MN988102600Medicaid
MN374R6MAOtherBCBS
MN988102600Medicaid