Provider Demographics
NPI:1871034850
Name:MAHONEY, KAITLIN
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
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 1:1924 ALCOA HWY # U-67
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1511
Mailing Address - Country:US
Mailing Address - Phone:865-305-9350
Mailing Address - Fax:865-305-9353
Practice Address - Street 1:250 S MAIN STREET
Practice Address - Street 2:SUITE 224A
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-4726
Practice Address - Country:US
Practice Address - Phone:540-552-7133
Practice Address - Fax:540-552-7143
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102206749207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program