MEDICARE: MRS. KAITLYN MARIE MAHAFFY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	4704360402	MI
2	163W00000X	Registered Nurse	4704360402	MI

General Provider Information

NPI Number	:	1023879657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KAITLYN MARIE MAHAFFY

Provider Business Mailing Address
First Line	:	1210 10TH AVE
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-3406
Country	:	US
Telephone Number	:	810-662-3505
Fax Number	:	810-662-3479

Provider Business Practice Location Address
First Line	:	1210 10TH AVE
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-3406
Country	:	US
Telephone Number	:	810-662-3505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2024
Last Update Date	:	01/22/2026

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