Provider Demographics
NPI:1184123101
Name:MATTISON, CHARLES LEE
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:MATTISON
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 1:4722 ENGLISH CT
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-3779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:240-216-8640
Practice Address - Street 1:4722 ENGLISH CT
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-3779
Practice Address - Country:US
Practice Address - Phone:240-216-8540
Practice Address - Fax:240-216-8640
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant