Provider Demographics
NPI:1629602479
Name:MATHAUN, MANDEEP K (LPN)
Entity Type:Individual
Prefix:
First Name:MANDEEP
Middle Name:K
Last Name:MATHAUN
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 1:5911 IVY SUMMIT CT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7136
Mailing Address - Country:US
Mailing Address - Phone:330-999-9315
Mailing Address - Fax:
Practice Address - Street 1:400 DAWSON COMMONS CIR STE 410
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6269
Practice Address - Country:US
Practice Address - Phone:706-344-1263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA097648164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse