Organization
MARLA MATHIS, FNP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARLA MATHIS FNP (OWNER)
(601) 467-0087
Entity
Organization
Contact information
Practice address
130 N MAIN ST, PETAL, MS 39465-2345
(601) 467-0087
(601) 450-0186
Mailing address
300 S 21ST AVE, HATTIESBURG, MS 39401-7319
(601) 467-0087
(601) 450-0186
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
852476
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00926271
—
MS
01
—
447640YUTG
MEDICARE PTAN INDIVIDUAL
MS
Enumeration date
06/10/2016
Last updated
06/10/2016
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