Provider Demographics
NPI:1841466182
Name:DEMATTIA, LISA NICOLE (PT/DPT/OCS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
Last Name:DEMATTIA
Suffix:
Gender:F
Credentials:PT/DPT/OCS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:NICOLE
Other - Last Name:LYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT/DPT/OCS
Mailing Address - Street 1:37354 VALLEY SPRING WAY
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-1854
Mailing Address - Country:US
Mailing Address - Phone:360-303-8714
Mailing Address - Fax:
Practice Address - Street 1:25495 MEDICAL CENTER DR STE 304
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562
Practice Address - Country:US
Practice Address - Phone:951-696-7474
Practice Address - Fax:951-696-7575
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2019-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA379392251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA119156Medicare PIN
CACB213022Medicare PIN
CAGE932ZMedicare PIN
CAW17215AMedicare PIN