1043019508 NPI number — MRS. LAUREN ASHLEY MATTOX PMHNP

Table of content: MRS. LAUREN ASHLEY MATTOX PMHNP (NPI 1043019508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043019508 NPI number — MRS. LAUREN ASHLEY MATTOX PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTOX
Provider First Name:
LAUREN
Provider Middle Name:
ASHLEY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATTOX
Provider Other First Name:
LAUREN
Provider Other Middle Name:
ASHLEY
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PMHNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1043019508
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2275 STROUD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30233-2812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-940-9262
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERDALE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30274-2640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-991-8500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/10/2025

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  254847 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)