Provider Demographics
NPI:1528383411
Name:MATA, LAURIE IRENE DAVIS (WHNP)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:IRENE DAVIS
Last Name:MATA
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:MRS
Other - First Name:LAURIE
Other - Middle Name:IRENE
Other - Last Name:MCCLURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RNP
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:866-682-4842
Mailing Address - Fax:209-383-1402
Practice Address - Street 1:797 W CHILDS AVE
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6805
Practice Address - Country:US
Practice Address - Phone:866-682-4842
Practice Address - Fax:209-383-1402
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16800363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health