Provider Demographics
NPI:1154601490
Name:ORGELLA-FANFAN, MATINA
Entity type:Individual
Prefix:
First Name:MATINA
Middle Name:
Last Name:ORGELLA-FANFAN
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 1:301 STERLING ST
Mailing Address - Street 2:APT 3G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-4147
Mailing Address - Country:US
Mailing Address - Phone:347-365-3139
Mailing Address - Fax:
Practice Address - Street 1:301 STERLING ST
Practice Address - Street 2:APT 3G
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-4147
Practice Address - Country:US
Practice Address - Phone:347-365-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303227164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse