Provider Demographics
NPI:1619564531
Name:MATHIS, JOHNETTA (LPN)
Entity Type:Individual
Prefix:
First Name:JOHNETTA
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16743 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3029
Mailing Address - Country:US
Mailing Address - Phone:313-477-7366
Mailing Address - Fax:
Practice Address - Street 1:16743 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3029
Practice Address - Country:US
Practice Address - Phone:313-477-7366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-26
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703121100164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse