Provider Demographics
NPI:1639470206
Name:MATHIS, HEATHER MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 HOSPITAL DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7384
Mailing Address - Country:US
Mailing Address - Phone:770-507-1344
Mailing Address - Fax:770-507-1377
Practice Address - Street 1:1010 HOSPITAL DR BLDG B
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7384
Practice Address - Country:US
Practice Address - Phone:770-507-1344
Practice Address - Fax:770-507-1377
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149754NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003113176AMedicaid
GA1639470206Medicare PIN