Provider Demographics
NPI:1518443357
Name:MATHIS, EDNA CAROL STEWARD (LPN)
Entity Type:Individual
Prefix:MS
First Name:EDNA CAROL
Middle Name:STEWARD
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:CHEYENNE
Other - Middle Name:
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:6707 FOREST PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2566
Mailing Address - Country:US
Mailing Address - Phone:912-335-1699
Mailing Address - Fax:
Practice Address - Street 1:6707 FOREST PARK DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2566
Practice Address - Country:US
Practice Address - Phone:912-335-1699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN076519164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse