Provider Demographics
NPI:1376246017
Name:MATHIS, DANYALE LAKEYTA
Entity Type:Individual
Prefix:MS
First Name:DANYALE
Middle Name:LAKEYTA
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 CALLAWAY LOOP
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3670
Mailing Address - Country:US
Mailing Address - Phone:678-682-5583
Mailing Address - Fax:
Practice Address - Street 1:1520 CALLAWAY LOOP
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3670
Practice Address - Country:US
Practice Address - Phone:678-682-5583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052873964343900000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)