Provider Demographics
NPI:1013987189
Name:MCMAHON, KELLY SUE (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 CEDAR CROSS RD STE 1
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52003-7748
Mailing Address - Country:US
Mailing Address - Phone:563-582-1000
Mailing Address - Fax:563-582-1113
Practice Address - Street 1:1075 CEDAR CROSS RD STE 1
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52003-7748
Practice Address - Country:US
Practice Address - Phone:563-582-1000
Practice Address - Fax:563-582-1113
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087220363LW0102X, 363LX0001X
WI7461-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0433433Medicaid
P26111Medicare UPIN
IA0433433Medicaid