Provider Demographics
NPI:1346973187
Name:MATHIS, DA'TWAN LAURICE (APRN)
Entity Type:Individual
Prefix:
First Name:DA'TWAN
Middle Name:LAURICE
Last Name:MATHIS
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4504
Mailing Address - Country:US
Mailing Address - Phone:863-688-3674
Mailing Address - Fax:
Practice Address - Street 1:517 BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4504
Practice Address - Country:US
Practice Address - Phone:863-688-3674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11020672363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily