Provider Demographics
NPI:1265619241
Name:MAHONEY, DEBRA SUE (FNP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:SUE
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4207
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-4207
Mailing Address - Country:US
Mailing Address - Phone:903-315-4105
Mailing Address - Fax:
Practice Address - Street 1:1600 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:GLADEWATER
Practice Address - State:TX
Practice Address - Zip Code:75647-5040
Practice Address - Country:US
Practice Address - Phone:903-315-5630
Practice Address - Fax:903-845-6212
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP109268363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS69511Medicare UPIN