Provider Demographics
NPI:1669474532
Name:MAHAN, KATHLEEN ELLEN (ARNP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ELLEN
Last Name:MAHAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13740 CYPRESS TERRACE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-8827
Mailing Address - Country:US
Mailing Address - Phone:239-275-5522
Mailing Address - Fax:239-275-4464
Practice Address - Street 1:7381 COLLEGE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5548
Practice Address - Country:US
Practice Address - Phone:239-482-1010
Practice Address - Fax:239-481-1481
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1343402363LF0000X
FLARNP1343402363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070980800Medicaid
FL303373200Medicaid
FLY4431WMedicare PIN
FL303373200Medicaid