Basic Information
| Provider Information | |||||||||
| NPI: | 1831748284 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHIS | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1509 DULLES DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705063718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379919276 | ||||||||
| FaxNumber: | 3379430846 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 VIA FORTUNA STE 510 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787467745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379919276 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2019 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 749592 | TX | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP143186 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.