Basic Information
| Provider Information | |||||||||
| NPI: | 1467011668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHERLY | ||||||||
| FirstName: | ANGELINA | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FORT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7067871745 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 ANDREWS AVENUE | ||||||||
| Address2: | |||||||||
| City: | FORT RUCKER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0082617193 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2019 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | N | Other Service Providers | Military Health Care Provider | 208D00000X | 2020-03801 | NC | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.