Provider Demographics
NPI:1649926189
Name:PRESTON, MATIETH NICOLE (LPN)
Entity type:Individual
Prefix:
First Name:MATIETH
Middle Name:NICOLE
Last Name:PRESTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-7615
Mailing Address - Country:US
Mailing Address - Phone:803-747-8600
Mailing Address - Fax:
Practice Address - Street 1:347 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-7615
Practice Address - Country:US
Practice Address - Phone:803-747-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39217.P164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse