Provider Demographics
NPI:1285824557
Name:MATTHEWS, WILMA EUPHRASIA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:WILMA
Middle Name:EUPHRASIA
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:WILMA
Other - Middle Name:EUPHRASIA
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19 SYLVAN ST
Mailing Address - Street 2:
Mailing Address - City:BAYSHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4232
Mailing Address - Country:US
Mailing Address - Phone:631-665-3560
Mailing Address - Fax:
Practice Address - Street 1:19 SYLVAN ST
Practice Address - Street 2:
Practice Address - City:BAYSHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-4232
Practice Address - Country:US
Practice Address - Phone:631-665-3560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0805701164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01097658Medicaid