Provider Demographics
NPI:1760570550
Name:MATHEWS, LEZLIE (CFNP)
Entity Type:Individual
Prefix:
First Name:LEZLIE
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 BROAD AVE
Mailing Address - Street 2:STE A
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2419
Mailing Address - Country:US
Mailing Address - Phone:228-392-7429
Mailing Address - Fax:228-396-3830
Practice Address - Street 1:1391 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2419
Practice Address - Country:US
Practice Address - Phone:228-863-8868
Practice Address - Fax:228-396-3830
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR830483363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00153898Medicaid
MS00153898Medicaid