Provider Demographics
NPI:1982322400
Name:MAHONEY, BRIANNA
Entity Type:Individual
Prefix:
First Name:BRIANNA
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 1:7204 AMHURST WAY
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-7001
Mailing Address - Country:US
Mailing Address - Phone:352-584-6394
Mailing Address - Fax:
Practice Address - Street 1:7204 AMHURST WAY
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-7001
Practice Address - Country:US
Practice Address - Phone:352-584-6394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11453133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered