Provider Demographics
NPI:1710162680
Name:IAMMATTEO, NICOLE CARLA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CARLA
Last Name:IAMMATTEO
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 1:4058 DEERWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1889
Mailing Address - Country:US
Mailing Address - Phone:651-994-9644
Mailing Address - Fax:
Practice Address - Street 1:2795 PILOT KNOB RD STE 100
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1930
Practice Address - Country:US
Practice Address - Phone:651-994-9644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102786225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist