Healthcare Provider Details

I. General information

NPI: 1548995186
Provider Name (Legal Business Name): COURTNEY LYNN MAHON RN, FNP, AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 GILMER ST
REIDSVILLE NC
27320-3809
US

IV. Provider business mailing address

709 N CARR ST
MEBANE NC
27302
UM

V. Phone/Fax

Practice location:
  • Phone: 336-342-6196
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number279115
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5016880
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: