Provider Demographics
NPI:1619684933
Name:MATUSALEM, MICHELLE VALLESTERO
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:VALLESTERO
Last Name:MATUSALEM
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 1:23 DUKE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1738
Mailing Address - Country:US
Mailing Address - Phone:908-444-0436
Mailing Address - Fax:
Practice Address - Street 1:23 DUKE ST
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1738
Practice Address - Country:US
Practice Address - Phone:908-444-0436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01393700363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health