Provider Demographics
NPI:1508231697
Name:MATTILA, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MATTILA
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 1:300 BROADWAY ST
Mailing Address - Street 2:#202
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1440
Mailing Address - Country:US
Mailing Address - Phone:612-788-4304
Mailing Address - Fax:
Practice Address - Street 1:300 BROADWAY ST
Practice Address - Street 2:#202
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1440
Practice Address - Country:US
Practice Address - Phone:612-788-4304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator