Provider Demographics
NPI:1346545233
Name:MATHIS, LORI L (ARNP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:MATHIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1378 NW 124TH ST
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8151
Mailing Address - Country:US
Mailing Address - Phone:515-288-6097
Mailing Address - Fax:515-288-8335
Practice Address - Street 1:1378 NW 124TH ST
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8151
Practice Address - Country:US
Practice Address - Phone:515-288-6097
Practice Address - Fax:515-288-8335
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-096152363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner