Provider Demographics
NPI:1861385387
Name:LASSITER/MATHIS, KEANNA
Entity type:Individual
Prefix:
First Name:KEANNA
Middle Name:
Last Name:LASSITER/MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 CALEDON WAY
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-5338
Mailing Address - Country:US
Mailing Address - Phone:229-942-4697
Mailing Address - Fax:
Practice Address - Street 1:580 CALEDON WAY
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-5338
Practice Address - Country:US
Practice Address - Phone:229-942-4697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty