Healthcare Provider Details

I. General information

NPI: 1629657028
Provider Name (Legal Business Name): KRISTEN MATHIES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 KENNETH DR
ROOTSTOWN OH
44272-9252
US

IV. Provider business mailing address

9317 WINDING CREEK DR
DIAMOND OH
44412-8742
US

V. Phone/Fax

Practice location:
  • Phone: 330-850-5141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCDCA.176333
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: