Provider Demographics
NPI:1427594472
Name:MATANANE, LENORA
Entity Type:Individual
Prefix:
First Name:LENORA
Middle Name:
Last Name:MATANANE
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 1:472 CHALAN SAN ANTONIO
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3605
Mailing Address - Country:US
Mailing Address - Phone:671-647-1830
Mailing Address - Fax:671-647-1919
Practice Address - Street 1:472 CHALAN SAN ANTONIO
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3605
Practice Address - Country:US
Practice Address - Phone:671-647-1830
Practice Address - Fax:671-647-1919
Is Sole Proprietor?:No
Enumeration Date:2017-01-15
Last Update Date:2017-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUD-38133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered