Provider Demographics
NPI:1922559012
Name:MCMAHON, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MCMAHON
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 1:7826 KOKO PL
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3624
Mailing Address - Country:US
Mailing Address - Phone:228-324-0974
Mailing Address - Fax:
Practice Address - Street 1:7826 KOKO PL
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3624
Practice Address - Country:US
Practice Address - Phone:228-324-0974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901814363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health