Provider Demographics
NPI:1639230162
Name:PAGE, MATILDA ANTIONETTE (ITS)
Entity Type:Individual
Prefix:MRS
First Name:MATILDA
Middle Name:ANTIONETTE
Last Name:PAGE
Suffix:
Gender:F
Credentials:ITS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 DREW CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-0348
Mailing Address - Country:US
Mailing Address - Phone:910-482-8009
Mailing Address - Fax:
Practice Address - Street 1:6958 NEXUS CT
Practice Address - Street 2:SUITE 102
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-2642
Practice Address - Country:US
Practice Address - Phone:910-423-5622
Practice Address - Fax:910-423-5538
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300019KMedicaid