Provider Demographics
NPI:1609963206
Name:IAMMATTEO, LAURENE TRICIA (DC)
Entity Type:Individual
Prefix:DR
First Name:LAURENE
Middle Name:TRICIA
Last Name:IAMMATTEO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2002
Mailing Address - Country:US
Mailing Address - Phone:718-442-8813
Mailing Address - Fax:718-876-0158
Practice Address - Street 1:1332 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-2002
Practice Address - Country:US
Practice Address - Phone:718-442-8813
Practice Address - Fax:718-876-0158
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008087-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01751091Medicaid
NYU59619Medicare UPIN
NY01751091Medicaid