Healthcare Provider Details

I. General information

NPI: 1790787505
Provider Name (Legal Business Name): KATHLEEN M MAHON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N
SAINT CLOUD MN
56303-2735
US

IV. Provider business mailing address

1200 6TH AVE N
SAINT CLOUD MN
56303-2735
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-5731
  • Fax: 320-240-2118
Mailing address:
  • Phone: 320-252-5731
  • Fax: 320-240-2118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR-121023-9
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: