Provider Demographics
NPI:1093341547
Name:MATFIELD, PHONAN J
Entity Type:Individual
Prefix:
First Name:PHONAN
Middle Name:J
Last Name:MATFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:PHONAN
Other - Middle Name:J
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:2691 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BEXLEY
Mailing Address - State:OH
Mailing Address - Zip Code:43209-2535
Mailing Address - Country:US
Mailing Address - Phone:614-420-6268
Mailing Address - Fax:
Practice Address - Street 1:2691 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BEXLEY
Practice Address - State:OH
Practice Address - Zip Code:43209-2535
Practice Address - Country:US
Practice Address - Phone:614-420-6268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.022855225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH33.022855OtherMASSAGE LICENSE