Provider Demographics
NPI:1639572217
Name:WILLIAMS, MATTHEW (LPN)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:
Other - Last Name:HACKETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:855 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97446-9588
Mailing Address - Country:US
Mailing Address - Phone:541-556-7170
Mailing Address - Fax:
Practice Address - Street 1:855 S 8TH ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:OR
Practice Address - Zip Code:97446-9588
Practice Address - Country:US
Practice Address - Phone:541-556-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-26
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201330118LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse