Provider Demographics
NPI:1801903596
Name:MATHIS, ELLISA A (FNP'C)
Entity type:Individual
Prefix:MISS
First Name:ELLISA
Middle Name:A
Last Name:MATHIS
Suffix:
Gender:F
Credentials:FNP'C
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Mailing Address - Street 1:800 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-7104
Mailing Address - Country:US
Mailing Address - Phone:912-287-4434
Mailing Address - Fax:912-287-9964
Practice Address - Street 1:409 UVALDA ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4574
Practice Address - Country:US
Practice Address - Phone:912-283-1359
Practice Address - Fax:912-283-1362
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2009-10-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARN068928363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily