Provider Demographics
NPI:1952159253
Name:EYONG EPSE EBAIETAKA, MATILDA OTANG (PMHNP)
Entity Type:Individual
Prefix:
First Name:MATILDA
Middle Name:OTANG
Last Name:EYONG EPSE EBAIETAKA
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6945 S OPAL DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-7221
Mailing Address - Country:US
Mailing Address - Phone:480-452-6424
Mailing Address - Fax:
Practice Address - Street 1:3755 S ROME STREET
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297
Practice Address - Country:US
Practice Address - Phone:480-677-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ223835363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health