Provider Demographics
NPI:1548718125
Name:MATHIS, CHANDRA (FNP-C)
Entity type:Individual
Prefix:
First Name:CHANDRA
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CHANDRA
Other - Middle Name:D
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1200 FORT ST STE A
Mailing Address - Street 2:
Mailing Address - City:BARLING
Mailing Address - State:AR
Mailing Address - Zip Code:72923-2013
Mailing Address - Country:US
Mailing Address - Phone:479-763-1511
Mailing Address - Fax:479-763-1545
Practice Address - Street 1:1200 FORT ST
Practice Address - Street 2:
Practice Address - City:BARLING
Practice Address - State:AR
Practice Address - Zip Code:72923
Practice Address - Country:US
Practice Address - Phone:479-763-1511
Practice Address - Fax:479-763-1545
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004908363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR221472758Medicaid