Healthcare Provider Details

I. General information

NPI: 1790054831
Provider Name (Legal Business Name): ELISE J MAHONEY FNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 NE 99TH AVE SUITE 100
PORTLAND OR
97220-9436
US

IV. Provider business mailing address

1500 NW BETHANY BLVD STE 200
BEAVERTON OR
97006-5236
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-4050
  • Fax:
Mailing address:
  • Phone: 503-741-2735
  • Fax: 503-308-7222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201502876NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61239945
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201502876NP-PP
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201502876NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: