Provider Demographics
NPI:1033800024
Name:MATHEW, THRESIAMMA
Entity Type:Individual
Prefix:
First Name:THRESIAMMA
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25502 PAINE CIR
Mailing Address - Street 2:
Mailing Address - City:STEVENSON RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91381-1532
Mailing Address - Country:US
Mailing Address - Phone:818-455-2586
Mailing Address - Fax:661-480-5496
Practice Address - Street 1:17419 LASSEN ST
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-1515
Practice Address - Country:US
Practice Address - Phone:818-455-2586
Practice Address - Fax:661-480-5496
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN457619163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse