Provider Demographics
NPI:1609053800
Name:MATERA, ANGELA L (MSN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:MATERA
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:635 MAIN ST
Mailing Address - Street 2:ATTN: CREDENTIALING DPT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:860-638-6601
Practice Address - Street 1:141 FRANKLIN ST
Practice Address - Street 2:FRANKLIN STREET COMMUNITY HEALTH CENTER
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-1014
Practice Address - Country:US
Practice Address - Phone:203-969-0802
Practice Address - Fax:203-357-0162
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT003207363LP0200X
NY438138363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care