Provider Demographics
NPI:1750833307
Name:MATTESON, DEREK (RN)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MATTESON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BULLOCKS POINT AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-5351
Mailing Address - Country:US
Mailing Address - Phone:401-437-1008
Mailing Address - Fax:401-433-3042
Practice Address - Street 1:42 CAPE RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-3292
Practice Address - Country:US
Practice Address - Phone:800-853-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN53309163WD0400X
MARN2341300163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator