Provider Demographics
NPI:1508093550
Name:MATHIS, KATHY SUE (RN)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:SUE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 WEYMOUTH CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-7432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:BACH SPECIALTY CLINIC
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000078901163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care