Provider Demographics
NPI:1700957214
Name:MATUKAITIS, ALICE (CRNP)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:MATUKAITIS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4612 WESTBRANCH HWY
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837
Mailing Address - Country:US
Mailing Address - Phone:570-523-3462
Mailing Address - Fax:
Practice Address - Street 1:10 E INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:SHAMOKIN
Practice Address - State:PA
Practice Address - Zip Code:17872-6804
Practice Address - Country:US
Practice Address - Phone:570-648-0582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN507564L163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50004271OtherBLUE CROSS PROVIDER NO.
PAMA1332162OtherBLUE SHIELD PROVIDER NO.