Provider Demographics
NPI:1972238384
Name:MATTA, ANGELICA MARIA (LDN, CNS, CHC)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIA
Last Name:MATTA
Suffix:
Gender:F
Credentials:LDN, CNS, CHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8246 NW 108TH AVE UNIT 6
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-5242
Mailing Address - Country:US
Mailing Address - Phone:954-663-5044
Mailing Address - Fax:
Practice Address - Street 1:8246 NW 108TH AVE UNIT 6
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-5242
Practice Address - Country:US
Practice Address - Phone:954-663-5044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND9931133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist