=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629094040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIELLE L MAHAFFEY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2006
-----------------------------------------------------
Last Update Date | 04/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 336 DEERFIELD RD
-----------------------------------------------------
City | BOONE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28607-5008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-262-4209
-----------------------------------------------------
Fax | 828-262-4103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 336 DEERFIELD RD
-----------------------------------------------------
City | BOONE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28607-5008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-262-4209
-----------------------------------------------------
Fax | 828-262-4103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 97-01472
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 97-01472
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------