Provider Demographics
NPI:1659427417
Name:MATHERNE, VICKI TESSITORE (CNM)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:TESSITORE
Last Name:MATHERNE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:VICKIE
Other - Middle Name:
Other - Last Name:MATHERNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:15192 HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-6475
Mailing Address - Country:US
Mailing Address - Phone:985-370-7953
Mailing Address - Fax:
Practice Address - Street 1:15813 PAUL VEGA MD DR STE 200
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1431
Practice Address - Country:US
Practice Address - Phone:985-230-7650
Practice Address - Fax:985-230-7655
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03301367A00000X
LARN064193367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1543314Medicaid
LAAP03301OtherMW LICENSE