Provider Demographics
NPI:1518340611
Name:MAHON, CLERISSA
Entity Type:Individual
Prefix:MRS
First Name:CLERISSA
Middle Name:
Last Name:MAHON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CLERISSA
Other - Middle Name:
Other - Last Name:AGONCILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:973-656-6280
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:97 W PARKWAY
Practice Address - Street 2:
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-1647
Practice Address - Country:US
Practice Address - Phone:973-831-5055
Practice Address - Fax:973-907-1086
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339432-1363LF0000X
NJ26NJ00591000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily