Provider Demographics
NPI:1891434882
Name:SPAN, MATTEA ROSE
Entity Type:Individual
Prefix:
First Name:MATTEA
Middle Name:ROSE
Last Name:SPAN
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 1:125 BALSAM ST
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-5203
Mailing Address - Country:US
Mailing Address - Phone:906-282-3134
Mailing Address - Fax:
Practice Address - Street 1:715 PYLE DR
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4456
Practice Address - Country:US
Practice Address - Phone:906-774-0522
Practice Address - Fax:906-774-1570
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI243214163WG0600X
MI4704340419163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WG0600XNursing Service ProvidersRegistered NurseGerontology