Provider Demographics
NPI:1619140340
Name:MATTOS, MYRNA L (RN)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:L
Last Name:MATTOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 DEVINE STREET
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29208-0001
Mailing Address - Country:US
Mailing Address - Phone:803-777-3658
Mailing Address - Fax:803-777-0126
Practice Address - Street 1:1409 DEVINE STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29208-0001
Practice Address - Country:US
Practice Address - Phone:803-777-3658
Practice Address - Fax:803-777-0126
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR106388208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice