Provider Demographics
NPI:1831373869
Name:MATTIACE, KATHLEEN J (RN)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:J
Last Name:MATTIACE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 PAULA BLVD
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2635
Mailing Address - Country:US
Mailing Address - Phone:631-846-8596
Mailing Address - Fax:
Practice Address - Street 1:10 HOLIDAY PARTK DR
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2111
Practice Address - Country:US
Practice Address - Phone:631-656-6813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3382751163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02381831Medicaid