Provider Demographics
NPI:1720559073
Name:MATIAS, CHRISTINA PETRA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:PETRA
Last Name:MATIAS
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 1:7645 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-6044
Mailing Address - Country:US
Mailing Address - Phone:847-401-8609
Mailing Address - Fax:
Practice Address - Street 1:7645 10TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6044
Practice Address - Country:US
Practice Address - Phone:847-401-8609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI222847163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse