Provider Demographics
NPI:1679009724
Name:MATHISEN, RACHEL CAROL
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:CAROL
Last Name:MATHISEN
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 1:5200 GREYSTONE SUMMIT DR
Mailing Address - Street 2:APT 308
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-7541
Mailing Address - Country:US
Mailing Address - Phone:732-533-8708
Mailing Address - Fax:
Practice Address - Street 1:120 LOUIE ST
Practice Address - Street 2:
Practice Address - City:WAGENER
Practice Address - State:SC
Practice Address - Zip Code:29164-9445
Practice Address - Country:US
Practice Address - Phone:803-564-8803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20972363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily