Provider Demographics
NPI:1164649794
Name:MATHIS, DEBRA LYNN (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:LYNN
Last Name:MATHIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:DEBRA
Other - Middle Name:LYNN
Other - Last Name:CROWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2804 REMINGTON GREEN CIR STE 2
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-1550
Mailing Address - Country:US
Mailing Address - Phone:850-385-4494
Mailing Address - Fax:850-298-6054
Practice Address - Street 1:1321 GEORGIA AVENUE
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:FL
Practice Address - Zip Code:32531-2605
Practice Address - Country:US
Practice Address - Phone:850-537-2700
Practice Address - Fax:850-537-2702
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1427202363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL99388OtherMEDICARE GROUP ASSOCIATION PTAN
FLARNP 1427202OtherFLORIDA MEDICAL LICENSE
FL000724900Medicaid
FLARNP 1427202OtherFLORIDA MEDICAL LICENSE