Provider Demographics
NPI: | 1922411420 |
---|---|
Name: | MATTHEW, JOANNE (APRN) |
Entity Type: | Individual |
Prefix: | |
First Name: | JOANNE |
Middle Name: | |
Last Name: | MATTHEW |
Suffix: | |
Gender: | F |
Credentials: | APRN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 7 COURT SQ |
Mailing Address - Street 2: | |
Mailing Address - City: | RUTLAND |
Mailing Address - State: | VT |
Mailing Address - Zip Code: | 05701-4030 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 802-775-4388 |
Mailing Address - Fax: | 802-775-3307 |
Practice Address - Street 1: | 7 COURT SQ |
Practice Address - Street 2: | |
Practice Address - City: | RUTLAND |
Practice Address - State: | VT |
Practice Address - Zip Code: | 05701-4030 |
Practice Address - Country: | US |
Practice Address - Phone: | 802-775-4388 |
Practice Address - Fax: | 802-775-3307 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2014-06-03 |
Last Update Date: | 2023-09-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
RI | CPPNS00106 | 364S00000X |
VT | 0125692 | 364SP0809X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 364SP0809X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health, Adult |
No | 364S00000X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VT | 1030508 | Medicaid |