Provider Demographics
NPI:1174909865
Name:MATHIS, PRISCILLA MAY
Entity type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:MAY
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:PRISCILLA
Other - Middle Name:MAY
Other - Last Name:RAINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4973 C A PICKARD RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-9031
Mailing Address - Country:US
Mailing Address - Phone:601-938-7136
Mailing Address - Fax:
Practice Address - Street 1:4973 C A PICKARD RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-9031
Practice Address - Country:US
Practice Address - Phone:601-938-7136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR885513 CN363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health