=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619899366
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY MAHANEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2026
-----------------------------------------------------
Last Update Date | 07/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 639 76TH AVE N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33702-5323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-351-5736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 639 76TH AVE N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33702-5323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-351-5736
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN11049552
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------