Provider Demographics
NPI:1073160966
Name:MATSON, CHEYENNE BROOKE
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:BROOKE
Last Name:MATSON
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 1:4642 S HAGADORN RD APT E5
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5325
Mailing Address - Country:US
Mailing Address - Phone:903-436-9143
Mailing Address - Fax:
Practice Address - Street 1:4642 S HAGADORN RD APT E5
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5325
Practice Address - Country:US
Practice Address - Phone:903-436-9143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-25
Last Update Date:2019-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant