Provider Demographics
NPI:1568963460
Name:MATA, ROSALYN YZETTA
Entity Type:Individual
Prefix:
First Name:ROSALYN
Middle Name:YZETTA
Last Name:MATA
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 1:270 COUNTY ROAD 3065
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-7790
Mailing Address - Country:US
Mailing Address - Phone:903-767-8304
Mailing Address - Fax:
Practice Address - Street 1:270 COUNTY ROAD 3065
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-7790
Practice Address - Country:US
Practice Address - Phone:903-767-8304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX185998164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse