Provider Demographics
NPI:1780850966
Name:MAHL, KATHLEEN ANN (APRN)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:MAHL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:MAHL
Other - Last Name:BOOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1375 CORPORATE SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3147
Mailing Address - Country:US
Mailing Address - Phone:985-726-2655
Mailing Address - Fax:985-643-9808
Practice Address - Street 1:56 STARBRUSH CIR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7208
Practice Address - Country:US
Practice Address - Phone:985-871-0095
Practice Address - Fax:985-871-0529
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN076670 AP05454363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1348228Medicaid
LA3A940CT87Medicare PIN