MEDICARE: MISS DEMESTRICE SHERISE MATHIS V LVN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	VN192486	CA

General Provider Information

NPI Number	:	1952670721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS DEMESTRICE SHERISE MATHIS V LVN

Provider Business Mailing Address
First Line	:	32845 SANTA CRUZ
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-0468
Country	:	US
Telephone Number	:	951-588-7713
Fax Number	:

Provider Business Practice Location Address
First Line	:	32845 SANTA CRUZ
Second Line	:	3822NEWARK CT
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92530-0468
Country	:	US
Telephone Number	:	951-588-7713
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/22/2011
Last Update Date	:	12/22/2011

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