Provider Demographics
NPI:1659608222
Name:MATHIS, SUSAN K (RN, APN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:MATHIS
Suffix:
Gender:F
Credentials:RN, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 YOUNG RD
Mailing Address - Street 2:
Mailing Address - City:MEDON
Mailing Address - State:TN
Mailing Address - Zip Code:38356-6850
Mailing Address - Country:US
Mailing Address - Phone:731-437-9424
Mailing Address - Fax:
Practice Address - Street 1:615 YOUNG RD
Practice Address - Street 2:
Practice Address - City:MEDON
Practice Address - State:TN
Practice Address - Zip Code:38356-6850
Practice Address - Country:US
Practice Address - Phone:731-437-9424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000147422163W00000X
TNAPN0000011878364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC327877Medicaid
SC327877Medicaid