Provider Demographics
NPI:1760692123
Name:MATTESON, SUZANNE ELIZABETH
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:MATTESON
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 1:1648 AHART ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-2102
Mailing Address - Country:US
Mailing Address - Phone:805-404-2756
Mailing Address - Fax:
Practice Address - Street 1:23357 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-4957
Practice Address - Country:US
Practice Address - Phone:310-456-9059
Practice Address - Fax:310-456-6529
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA197183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician