Provider Demographics
NPI:1285618298
Name:MATTA, GLORIA I (RNP)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:I
Last Name:MATTA
Suffix:
Gender:F
Credentials:RNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1172 N. MACLAY AVE.
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340
Mailing Address - Country:US
Mailing Address - Phone:818-898-1388
Mailing Address - Fax:818-365-4031
Practice Address - Street 1:8215 VAN NUYS BLVD.
Practice Address - Street 2:SUITE 306
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402
Practice Address - Country:US
Practice Address - Phone:818-988-6335
Practice Address - Fax:818-988-2140
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 124363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology