Provider Demographics
NPI:1174024574
Name:MATA, AUDREA CELESTE (LVN)
Entity Type:Individual
Prefix:MS
First Name:AUDREA
Middle Name:CELESTE
Last Name:MATA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 54TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-4042
Mailing Address - Country:US
Mailing Address - Phone:806-407-4719
Mailing Address - Fax:
Practice Address - Street 1:3430 54TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-4042
Practice Address - Country:US
Practice Address - Phone:806-407-4719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209289164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse