Provider Demographics
NPI:1255659892
Name:MATA, GISELLE ALICIA (FNP)
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:ALICIA
Last Name:MATA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17360 BROOKHURST STREET
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT.
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:657-241-3592
Mailing Address - Fax:714-665-4614
Practice Address - Street 1:1212 W 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-3418
Practice Address - Country:US
Practice Address - Phone:714-377-2348
Practice Address - Fax:714-377-2866
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP19537363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner