Provider Demographics
NPI:1679248124
Name:MATHIS, KALIE DEANN (NP-C)
Entity Type:Individual
Prefix:
First Name:KALIE
Middle Name:DEANN
Last Name:MATHIS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:360 E WASHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31503-0680
Mailing Address - Country:US
Mailing Address - Phone:912-548-4230
Mailing Address - Fax:
Practice Address - Street 1:505 CITY BLVD
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-8003
Practice Address - Country:US
Practice Address - Phone:912-490-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN279071363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics