Healthcare Provider Details

I. General information

NPI: 1194183137
Provider Name (Legal Business Name): GWENDOLYN MATHIS DNP-APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 NORTH DR STE 3100
DALLAS TX
75207-4431
US

IV. Provider business mailing address

315 W ELLIOT RD STE 107-149
TEMPE AZ
85284-1328
US

V. Phone/Fax

Practice location:
  • Phone: 802-287-6030
  • Fax:
Mailing address:
  • Phone: 802-287-6030
  • Fax: 602-584-6216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number834633
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20988
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number249010
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number20988
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1142764
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number20988
License Number StateTN
# 7
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberF0116574
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: