Healthcare Provider Details

I. General information

NPI: 1992951107
Provider Name (Legal Business Name): LWAFP PC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 NW BUNNELL AVE
GRANTS PASS OR
97526-6012
US

IV. Provider business mailing address

PO BOX 1925
GRANTS PASS OR
97528-0163
US

V. Phone/Fax

Practice location:
  • Phone: 541-474-9400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA MAHONEY
Title or Position: PRESIDENT
Credential: MSN, FNP
Phone: 541-474-9400