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General NPI Number Information
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NPI Number | 1285083238
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Entity Type | Organization
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Legal Business Name | MARLA MATHIS, FNP
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Dates
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Enumeration Date | 06/10/2016
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Last Update Date | 06/10/2016
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Provider Practice Location Address
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Address Line | 130 N MAIN ST
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City | PETAL
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State | MS
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Zip | 39465-2345
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Country | US
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Telephone | 601-467-0087
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Fax | 601-450-0186
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Provider Business Mailing Address
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Address Line | 300 S 21ST AVE
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City | HATTIESBURG
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State | MS
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Zip | 39401-7319
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Country | US
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Telephone | 601-467-0087
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Fax | 601-450-0186
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Authorized Official
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Title or Position | OWNER
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Name | MARLA MATHIS
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Credential | FNP
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Telephone | 601-467-0087
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 852476
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License Number State | MS
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