Provider Demographics
NPI:1063479541
Name:MATTISON, PAMELA JEAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:JEAN
Last Name:MATTISON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 GLENMONT RD
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-8020
Mailing Address - Country:US
Mailing Address - Phone:715-425-7880
Mailing Address - Fax:
Practice Address - Street 1:252 GLENMONT RD
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-8020
Practice Address - Country:US
Practice Address - Phone:715-425-7880
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI89371-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39911900Medicaid