Provider Demographics
NPI:1750850111
Name:MAHONEY, DEBRA SPANO
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:SPANO
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-5382
Mailing Address - Country:US
Mailing Address - Phone:772-461-3890
Mailing Address - Fax:772-468-2134
Practice Address - Street 1:2201 S 10TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-5382
Practice Address - Country:US
Practice Address - Phone:772-461-3890
Practice Address - Fax:772-468-2134
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5164156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician