Healthcare Provider Details

I. General information

NPI: 1043019508
Provider Name (Legal Business Name): LAUREN ASHLEY MATTOX PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAUREN ASHLEY MATTOX PMHNP

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 03/10/2025
Certification Date: 03/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 MEDICAL CENTER DR
RIVERDALE GA
30274-2640
US

IV. Provider business mailing address

2275 STROUD RD
JACKSON GA
30233-2812
US

V. Phone/Fax

Practice location:
  • Phone: 770-991-8500
  • Fax:
Mailing address:
  • Phone: 770-940-9262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number254847
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: