Provider Demographics
NPI:1669291910
Name:DIMATTIA, DRAE
Entity type:Individual
Prefix:
First Name:DRAE
Middle Name:
Last Name:DIMATTIA
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 1:4916 HOPE ST
Mailing Address - Street 2:
Mailing Address - City:RIVER OAKS
Mailing Address - State:TX
Mailing Address - Zip Code:76114-2949
Mailing Address - Country:US
Mailing Address - Phone:316-322-5223
Mailing Address - Fax:
Practice Address - Street 1:4916 HOPE ST
Practice Address - Street 2:
Practice Address - City:RIVER OAKS
Practice Address - State:TX
Practice Address - Zip Code:76114-2949
Practice Address - Country:US
Practice Address - Phone:316-322-5223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS150871163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care