Provider Demographics
NPI:1659679462
Name:MATTISON, SALIA
Entity Type:Individual
Prefix:
First Name:SALIA
Middle Name:
Last Name:MATTISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SALIA
Other - Middle Name:
Other - Last Name:MCMILLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 QUADRANGLE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-1492
Mailing Address - Country:US
Mailing Address - Phone:407-266-3627
Mailing Address - Fax:407-882-4799
Practice Address - Street 1:3400 QUADRANGLE BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817
Practice Address - Country:US
Practice Address - Phone:407-266-3627
Practice Address - Fax:407-882-4799
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN176496363LF0000X
FLARNP9351557363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024674400Medicaid