Provider Demographics
NPI:1982169017
Name:MAHONEY, KERYN
Entity Type:Individual
Prefix:
First Name:KERYN
Middle Name:
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 1:10 PATRIOT PKWY APT 313
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-0016
Mailing Address - Country:US
Mailing Address - Phone:617-571-3296
Mailing Address - Fax:
Practice Address - Street 1:10 PATRIOT PKWY APT 313
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-0016
Practice Address - Country:US
Practice Address - Phone:617-571-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-03
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN254065163WM0705X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical