Provider Demographics
NPI:1659122950
Name:MATHIS, TERESA LYNN
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNN
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 N CALUMET DR
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41183-9607
Mailing Address - Country:US
Mailing Address - Phone:731-607-0380
Mailing Address - Fax:
Practice Address - Street 1:1454 N CALUMET DR
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:KY
Practice Address - Zip Code:41183-9607
Practice Address - Country:US
Practice Address - Phone:731-607-0380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant