Provider Demographics
NPI:1285303362
Name:MATTOX, BRITNEY
Entity type:Individual
Prefix:
First Name:BRITNEY
Middle Name:
Last Name:MATTOX
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 1:5073 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-5610
Mailing Address - Country:US
Mailing Address - Phone:141-455-0454
Mailing Address - Fax:
Practice Address - Street 1:5073 N 24TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-5610
Practice Address - Country:US
Practice Address - Phone:141-455-0454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0017645372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI833124808Medicaid