Provider Demographics
NPI:1417637273
Name:MATTESSICH, KRISTA M (LPN)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:M
Last Name:MATTESSICH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:M
Other - Last Name:BOWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:527 N MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-1227
Mailing Address - Country:US
Mailing Address - Phone:330-797-0070
Mailing Address - Fax:330-797-9146
Practice Address - Street 1:527 N MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-1227
Practice Address - Country:US
Practice Address - Phone:330-797-0070
Practice Address - Fax:330-797-9146
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.164610.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse