Provider Demographics
NPI:1134321581
Name:MATTICKS, DONNA MARIA (RN)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIA
Last Name:MATTICKS
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 1:6309 WIND TREE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62712-3738
Mailing Address - Country:US
Mailing Address - Phone:217-899-7524
Mailing Address - Fax:217-529-9514
Practice Address - Street 1:6309 WIND TREE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62712-3738
Practice Address - Country:US
Practice Address - Phone:217-899-7524
Practice Address - Fax:217-529-9514
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
IL163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Not Answered163WC1500XNursing Service ProvidersRegistered NurseCommunity Health