Provider Demographics
NPI:1780156646
Name:MAHONEY, SUZANNE MARIE
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARIE
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 1:475 LITTLE AVE
Mailing Address - Street 2:
Mailing Address - City:COTTRELLVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48039-2813
Mailing Address - Country:US
Mailing Address - Phone:313-806-9880
Mailing Address - Fax:
Practice Address - Street 1:475 LITTLE AVE
Practice Address - Street 2:
Practice Address - City:COTTRELLVILLE
Practice Address - State:MI
Practice Address - Zip Code:48039-2813
Practice Address - Country:US
Practice Address - Phone:313-806-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703108942164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse