Provider Demographics
NPI:1346836301
Name:DE MATTA, KASSANDRA MARYCELA
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:MARYCELA
Last Name:DE MATTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4423 LONG BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90058-1922
Mailing Address - Country:US
Mailing Address - Phone:323-360-2893
Mailing Address - Fax:
Practice Address - Street 1:4423 LONG BEACH AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90058-1922
Practice Address - Country:US
Practice Address - Phone:323-360-2893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program