Provider Demographics
NPI:1679975825
Name:MATHIS, PAMELA DENISE
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:DENISE
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 1:11120 W VAN BUREN ST APT 2117
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-7304
Mailing Address - Country:US
Mailing Address - Phone:602-243-1773
Mailing Address - Fax:602-276-1984
Practice Address - Street 1:11120 W VAN BUREN ST APT 2117
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-7304
Practice Address - Country:US
Practice Address - Phone:602-243-1773
Practice Address - Fax:602-276-1984
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ48661563747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant