Provider Demographics
NPI:1417228016
Name:ST GERMAIN, MATTHEW SHANE DONNELLY (RN, LMT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SHANE DONNELLY
Last Name:ST GERMAIN
Suffix:
Gender:M
Credentials:RN, LMT
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:SHANE
Other - Last Name:DONNELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, LMT
Mailing Address - Street 1:144 WATERMAN ST STE 5
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2126
Mailing Address - Country:US
Mailing Address - Phone:401-413-7525
Mailing Address - Fax:
Practice Address - Street 1:422 POST RD
Practice Address - Street 2:SUITE G2
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-2802
Practice Address - Country:US
Practice Address - Phone:401-467-9193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-13
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI705172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist