Provider Demographics
NPI:1770190928
Name:MATHEWS, TERRY LYNN
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LYNN
Last Name:MATHEWS
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 1:1105 KNIGHT CHASE DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-2074
Mailing Address - Country:US
Mailing Address - Phone:470-651-0674
Mailing Address - Fax:
Practice Address - Street 1:1115 MOUNT ZION RD STE 15
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2241
Practice Address - Country:US
Practice Address - Phone:470-651-0674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABL0017822019343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)