Healthcare Provider Details

I. General information

NPI: 1871034850
Provider Name (Legal Business Name): KAITLIN MAHONEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S MAIN STREET SUITE 224A
BLACKSBURG VA
24060-4726
US

IV. Provider business mailing address

1924 ALCOA HWY # U-67
KNOXVILLE TN
37920-1511
US

V. Phone/Fax

Practice location:
  • Phone: 540-552-7133
  • Fax: 540-552-7143
Mailing address:
  • Phone: 865-305-9350
  • Fax: 865-305-9353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0102206749
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: