Provider Demographics
NPI:1649655952
Name:MATOTT, DEZERAY CLARE (NP)
Entity type:Individual
Prefix:DR
First Name:DEZERAY
Middle Name:CLARE
Last Name:MATOTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:DEZERAY
Other - Middle Name:CLARE
Other - Last Name:TOMESH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12961 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-5699
Mailing Address - Country:US
Mailing Address - Phone:715-738-3700
Mailing Address - Fax:
Practice Address - Street 1:12961 27TH AVE
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-5699
Practice Address - Country:US
Practice Address - Phone:715-738-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6503-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily