Healthcare Provider Details

I. General information

NPI: 1023879657
Provider Name (Legal Business Name): MRS. KAITLYN MARIE MAHAFFY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. KAITLYN MARIE AMEY

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2026
Certification Date: 01/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 10TH AVE
PORT HURON MI
48060-3406
US

IV. Provider business mailing address

1210 10TH AVE
PORT HURON MI
48060-3406
US

V. Phone/Fax

Practice location:
  • Phone: 810-662-3505
  • Fax:
Mailing address:
  • Phone: 810-662-3505
  • Fax: 810-662-3479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704360402
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704360402
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: