Provider Demographics
NPI:1164011763
Name:MATHIS, CIERRA LAZANA (RDN, LDN, MED)
Entity Type:Individual
Prefix:
First Name:CIERRA
Middle Name:LAZANA
Last Name:MATHIS
Suffix:
Gender:F
Credentials:RDN, LDN, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 TENNEL RD
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:FL
Mailing Address - Zip Code:32343-2607
Mailing Address - Country:US
Mailing Address - Phone:850-459-1025
Mailing Address - Fax:
Practice Address - Street 1:2633 CENTENNIAL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0606
Practice Address - Country:US
Practice Address - Phone:850-431-5404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty