=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457177644
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELIQUE LASHA MATHIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2024
-----------------------------------------------------
Last Update Date | 12/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9556 PUCKER ST
-----------------------------------------------------
City | BERRIEN CENTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49102-9717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-635-3769
-----------------------------------------------------
Fax | 269-213-3303
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9556 PUCKER ST
-----------------------------------------------------
City | BERRIEN CENTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49102-9717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-635-3769
-----------------------------------------------------
Fax | 269-213-3303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number | AS1110418243
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------