Provider Demographics
NPI:1942838412
Name:PRITIKIN, MATTHEW W (RN)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:W
Last Name:PRITIKIN
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 1:1316 SW BABCOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7303
Mailing Address - Country:US
Mailing Address - Phone:954-701-0478
Mailing Address - Fax:
Practice Address - Street 1:1316 SW BABCOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-7303
Practice Address - Country:US
Practice Address - Phone:954-701-0478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9372893163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9372893OtherFLORIDA BOARD OF HEALTH/NURSING