Provider Demographics
NPI:1932823739
Name:MATOS, AMANDA LAUREN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LAUREN
Last Name:MATOS
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 1:13 JILLIAN WAY
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790-4231
Mailing Address - Country:US
Mailing Address - Phone:774-319-1074
Mailing Address - Fax:
Practice Address - Street 1:450 VETERANS MEMORIAL PKWY STE 8C
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-5300
Practice Address - Country:US
Practice Address - Phone:401-396-9331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered