Provider Demographics
NPI:1952670721
Name:MATHIS, DEMESTRICE SHERISE V (LVN)
Entity Type:Individual
Prefix:MISS
First Name:DEMESTRICE
Middle Name:SHERISE
Last Name:MATHIS
Suffix:V
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32845 SANTA CRUZ
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-0468
Mailing Address - Country:US
Mailing Address - Phone:951-588-7713
Mailing Address - Fax:
Practice Address - Street 1:32845 SANTA CRUZ
Practice Address - Street 2:3822NEWARK CT
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-0468
Practice Address - Country:US
Practice Address - Phone:951-588-7713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN192486164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse