Provider Demographics
NPI:1285083238
Name:MARLA MATHIS, FNP
Entity type:Organization
Organization Name:MARLA MATHIS, FNP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-467-0087
Mailing Address - Street 1:300 S 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7319
Mailing Address - Country:US
Mailing Address - Phone:601-467-0087
Mailing Address - Fax:601-450-0186
Practice Address - Street 1:130 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2345
Practice Address - Country:US
Practice Address - Phone:601-467-0087
Practice Address - Fax:601-450-0186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS852476363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00926271Medicaid
MS447640YUTGOtherMEDICARE PTAN INDIVIDUAL