Healthcare Provider Details

I. General information

NPI: 1902899362
Provider Name (Legal Business Name): MORIAH B. MAHONEY CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

IV. Provider business mailing address

3304 MOUNTAIN RD NE
ALBUQUERQUE NM
87106-1920
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-4985
  • Fax: 505-471-6084
Mailing address:
  • Phone: 505-426-7686
  • Fax: 505-471-6084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP01287
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR53421
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberCNP01287
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: