Provider Demographics
NPI:1093360653
Name:MATTESON, CHANDRA A (NP-C)
Entity Type:Individual
Prefix:
First Name:CHANDRA
Middle Name:A
Last Name:MATTESON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4946 N RIDGEWAY AVE # 1R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-6006
Mailing Address - Country:US
Mailing Address - Phone:415-845-7642
Mailing Address - Fax:
Practice Address - Street 1:4946 N RIDGEWAY AVE # 1R
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-6006
Practice Address - Country:US
Practice Address - Phone:415-845-7642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019807363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily