Provider Demographics
NPI:1922580026
Name:MAHONEY, KELLY (PMHNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W HARGETT ST APT 406
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-4059
Mailing Address - Country:US
Mailing Address - Phone:910-603-6162
Mailing Address - Fax:
Practice Address - Street 1:33 TOWER ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1426
Practice Address - Country:US
Practice Address - Phone:617-591-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2392682084P0800X
MARN2357709363LP0808X
NC5010931363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry